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Lectures  on  Syphilis. 


DELIVERED  AT  THE 


Chicago  College  o[  Plijsicians  and  Surgeons. 


BY 


G.  Frank  Lydston,  M.  D. 


Late  Eesideut  Surgeon  at  Charity  Hospital,  and  at  State  Emigration 
Refuge  and  Hospital,  New  York  City.    Lecturer  on  the  Surgical 
Diseases  of  the  Genito -Urinary  organs,  and  on  Venereal  Dis- 
eases, in  the  College  of  Physicians  and  Surgeons.    Professor 
of  the  Principles  and  Practice  of  Surgery  in  the  North- 
Western    College   of   Dental   Surgery.     Attending 
Surgeon  to  the  Genito-Urinary  and  Venereal  de- 
partment of    the   West   Side   Dispensary. 
Member  of  the  Chicago  Medical  Society, 
of  the  Chicago  Pathological  Society, 
Etc.,  Etc. 


Repokted  by 
WM.  A.  WALKER,  A.  M. ,  M.  D. 

Attending  Physician  to  the  West  Side  Dispensary. 


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J»M^iff«mm  (&  Co.,  Publishers. 

1885. 


COPXR\GHT,  \?)ab,  BX  G>.  V^kVWv  L^\)STOH,  V^.  Q. 


n.vA- 


O'Neil  &  Gkiswoi,©,  Binders,  Chicago. 


TO 

JOSEPH  W.  HOWE,  M.  D., 

late    professok   of  clinical  surgery  at  the 
bellevue  hospital  medical  college ;  surg- 
eon to  the  charity  hospital,  and 
to  st.  francis'  hospital  of 
new  york  city, 

These   Lectures 

are  affectionately  inscribed,  in  memory  of  pleasant 

hours  of  study,  by  his  sincere  friend 

and    grateful    pupil, 

The  Author. 


PREFACE. 


These  lectures  were  originally  published  in  The  Western 
Medical  Reporter,  and  they  have  been  collected  and  re- 
published in  their  present  form,  with  but  little  revision.  An 
earnest  attempt  has  been  made  to  present  to  the  student  a 
plain  and  practical  idea  of  the  subject  of  Syphilis,  as  taught 
by  our  most  advanced  pathologists  and  syphilographers,  in 
conjunction  with  practical  points  drawn  from  personal  observa- 
tion in  hospital  and  dispensary  practice.  The  views  of 
Fessenden  Otis  have  been  adopted,  as  the  most  logical  and 
scientific  which  have  yet  been  offered,  in  explanation  of  the 
pathological  phenomena  of  the  disease.  It  is  hoped  that  these 
few  lectures  may  prove  more  valuable  to  the  student,  than 
some  of  the  larger  and  more  comprehensive  treatises. 

125  State  Street,  Oct.  1st,  1885. 


CONTENTS. 


Lecture  I.  Definition  of  syphilis.  Its  contagiousness  and 
wide  diflEusion.  Origin  of  tlie  disease.  Its  decreasing  ma- 
lignancy. Diiality  of  syphilis  and  chancroid.  Experiments 
with  animals.  Period  of  incubation.  The  syphilitic  cell. 
Harmony  of  the  bacillar  theory  with  the  physiological  path- 
ology of  syphilis Page  9. 

Lecture  II.  Initiatory  period.  Importance  of  the  syphilitic 
ceU.  Anatomy  and  histology  of  local  manifestations  of  the 
disease.  Adenopathy.  Varieties  of  induration.  Necrobiosis. 
Chancrous  secretion.  "Vaccinal  syphilis.  Poison  bearing 
secretions  of  syphilis.  Dependence  of  contagiousness  on  the 
syphilitic  cell Page  29. 

Lectuke  III.  Modes  of  transmitting  syphilis.  Absence  of 
primary  syphilis  in  foetal  infection.  Infection  by  kissing. 
Colle's  law.  Danger  of  infection  by  syphilitic  child.  Illus- 
trations of  methods  of  transmission.  Varieties  and  treatment 
of  chancre.     Mixed  sores.     Syphilitic  bubo Page  47. 

Lecture  IV.  Period  of  general  infection.  Progression  of 
syphilitic  cells.  Apparent  periods  of  incubation.  The  rose- 
ola. Syphilitic  fever  or  prodromes.  Syphilitic  sore  throat. 
The  papule.  Alopecia.  Onychia.  Pustules,  ulcers,  mucous 
patches,  tubercles,  and  condylomata.  Iritis.  Duration  of 
active  period Page  67. 

Lecture  V.  Period  of  sequels  or  tertiary  period.  Syphil- 
omata,  or  gummata.  Tendency  to  necrosis  of  gummata. 
Non-inf  ectiousness  of  gummy  material.  Lymphatic  obstruc- 
tion. Stages  of  syphilis.  Precocious  syphiHs.  Syphilides. 
Duration  of  syphilis.  Prognosis  of  syphilis.  A  typical  case 
of  syphilis Page  93. 


Lecture  YI.  Treatment  of  syphilis.  Excision  of  chancre. 
Effects  of  mercury.  Action  upon  the  blood.  Action  of 
iodine.  Proper  time  and  inethod  of  giving  mercury.  Dura- 
tion of  treatment Page  113. 

Lecture  VII.  Evil  effects  of  mercury.  Popular  prejudice 
against  its  use.  Mercurial  depression,  ptyalism,  stomatitis, 
rheumatism,  and  possible  ulceration  and  necrosis.  Iodides 
in  syphilis.  Injurious  effects  of  the  iodides.  Questionable 
preparations  in  syphilis.  Local  measures.  Syphilitic  necro- 
sis  Page  133. 

Lecture  VIII.  Congenital  and  acquired  syphilis  in  children. 
Methods  of  hereditary  transmission.  Intra-uterine  syphi- 
lis, and  syphilitic  abortion.  Masquerading  of  syphilis  in 
children.  Appearance  of  the  syphilitic  child.  Hutchin- 
son's description.  Lesions  in  the  child.  Apoplectic  effu- 
sions. Hydrocephalus.  Sudden  death.  Prognosis  and  treat- 
ment  Page  149. 

Lecture  IX.  The  nursing  of  syphilitic  children.  Possibility 
of  healthy  child  being  bom  of  syphilitic  mother.  Attenu- 
ation of  virus.  Hutchinson's  views.  Escape  of  child  after 
seventh  month  of  pregnancy.  Insusceptibility  to  infection. 
Danger  of  infection  in  nursing.  Desirability  of  artificial 
feeding Page  169. 

APPENDIX. 


Selected  formulae  for  the  treatment  of  syphiHs. ,  .Page  177. 


Lecture  I. 

DefiBitlon  of  syphilis.— Contagiousness  of  the  disease.— Its  wide  diffu- 
sion.—Origin  of  syphilis. — Ancient  knowledge  of  the  disease.— Its 
present  benignity  as  contrasted  with  former  malignancy.— Expla- 
nation of  the  decrease  in  malignancy  by  evolutionary  laws.— Duality 
of  syphilis  and  chancroid.— Attempted  inoculation  of  animals  with 
syphilis.— Successful  inoculation  of  the  monkey. —Rapidity  of  absorp- 
tion of  syphilitic  poison.— Second  attacks  of  the  disease.— Venereal 
diseases  of  the  lower  animals.— Duration  of  incubation  period  of 
syphilis.— Peculiar  induration  of  chancre.— Nature  and  local  results 
of  the  syphilitic  materies  morbi.— Properties  of  the  syphilitic  cell.— 
Its  effects  and  importance  during  the  natural  course  of  syphilis.— Har- 
mony of  the  bacillar  theory  with  the  "physiological  pathology"  of 
syphilis. 

Gentlemen: — We  take  up  this  morning  the  most 
important  subject  which  it  is  my  privilege  to  pre- 
sent to  you,  and  the  most  interesting  of  those 
affections  classed  as  venereal  diseases.  Syphilis, 
or  as  it  is  sometimes  termed  "lues",  is  a  dyscrasic 
or  constitutional  affection  of  the  type  known  as 
"blood  diseases,"  due  to  the  infection  of  the  organ- 
ism of  a  human  being  with  a  peculiar  morbific  prin- 
ciple, or  virus,  or  hypothetically,  a  germinal 
disease  cell,  unknown  as  an  entity,  but  plainly 
manifest  in  its  pathological  results.  Its  manifes- 
tations are,  to  all  intents  and  purposes,  a  lesion 
which  is  primarily  local,  but  which  is  followed  by 
a  succession  of  morbid  constitutional  manifestations 
appearing  at  variable  intervals,  running  a  some- 
what definite  course,  and  being  more  or  less 
amenable  to  treatment.  The  virus  of  syphilis  has 
not  yet  been  isolated,  although  we  are  justified  in 


10  Lectures  on  Syphilis. 

the  hypothesis  that  it  is  a  degraded  cell  of  micro- 
scopic size,  and  possessed  of  most  potent  evil  pro- 
pensities. In  many  respects  syphilis  resembles 
the  exanthemata,  inasmuch  as  it  is  transmissible 
from  the  diseased  to  healthy  individuals,  has  a 
period  of  incubation,  a  stage  of  eruption,  another 
of  decline,  and  a  period  of  true  sequelae.  A  very 
minute  quantity  of  the  syphilitic  virus  is  sufficient 
to  produce  the  disease,  although  it  is  fortunate- 
ly only  contagious,  and  not  infectious,  in  the 
proper  sense  of  the  term.  The  wide  diffusion  of 
syphilis  through  the  human  famil}^,  will  not  be 
fully  appreciated  by  you,  until  you  enter  private 
practice,  when,  especially  if  your  field  of  labor 
lies  in  a  large  city,  you  will  soon  come  to  believe 
that  no  one  is  above  suspicion.  Perhaps  this  is  an 
exaggeration,  but  it  is  certain  that  syphilis,  like 
accidents,  is  liable  to  occur  in  the  best  regulated  of 
families,  and  often  serves  to  explain  otherwise 
obscure  cases  of  aristocratic  aches  and  invalidism. 
The  origin  of  syphilis  is  not  definitely  known, 
but  it  is  probably  quite  an  old  and  respectable 
disease  inasmuch  as  it  is  more  than  likely  that 
some  of  the  forms  of  leprosy  of  bible  times,  were 
instances  of  syphilis.  Indeed,  syphilis  and  leprosy 
were  confounded  only  a  few  centuries  ago.  Nearly 
all  accounts  of  syphilis  state  that  the  disease  a[)- 


Lydston.  11 

peared  in  Southern  Europe  in  the  latter  part  of  the 
fifteenth  century,  the  supposition  being  that  it  was 
imported  from  America  by  the  sailors  who  accom- 
panied Columbus  or  Amerigo  Yespucci  upon  their 
expeditions.     The  morals  of  the  country  at  that 
time  being  none  too   rigid,    the    disease    spread 
rapidly,  being  later  mistaken  for  leprosy.     It  has 
since  been  recognized  in  every  part  of  the  world, 
as  a  distinct  disease,  and  has  come  to  be  quite  well 
understood.     There  is  a  fact   connected  with  the 
history  of  syphilis,  which  is  not  generally  known, 
that  may  be  of  interest :     I  am  informed  upon  re- 
liable authority,  that  the  disease  was  described  by 
the  Japanese  historians  several  thousand  years  ago, 
and  that  documents  are  still  in  existence,  which 
contain  ancient  descriptions  of  the  affection,  that 
are  exceedingly  accurate.     This  would  indicate  the 
Asiatic  origin  of  the  disease,  it  having  been  brought 
to  America  by  those  nomadic  tribes  who  settled 
this  country  some  centuries  ago,  when  America  and 
Asia  were  united  by  the  peninsula  now  represented 
by  the  Aleutian  Islands.     As  still  further  evidence 
of  the  antiquity  of  syphilis,  may  be  mentioned  the 
fact  that   recent  translations  of   ancient   Chinese 
medical  writings  show  that  the  disease  was  known 
in  China  two  thousand  years  ago.     Moses  was  un- 
doubtedly familiar  with  the  disease,  a  fact  which 


12  Lectures  on  Syphilis, 

makes  it  still  more  ancient  and  respectable.  Dur- 
ing the  earlier  ^^ears  of  the  existence  of  syphilis  in 
Europe  it  was  so  malignant  and  widely  dissemi- 
nated, as  to  have  been  recognized  as  a  form  of 
plague,  which  created  great  havoc,  and  in  fact 
nearly  destroyed  the  various  armies  of  the  coun- 
tries afflicted.  The  disease,  has  gradually  grown 
milder  in  type  until  at  the  present  day  the  very 
severe  and  exceptional  cases  have  come  to  be 
classed  under  the  head  of  ' '  malignant. "  Now  there 
must  be  some  explanation  for  this,  and  I  think  it 
would  be  well  to  digress  slightly,  and  see  if  we 
cannot  find  logical  reasons  for  the  steady  diminu- 
tion in  the  virulence  of  syphilis.  In  the  first  place 
it  is  obvious  that  improved  sanitation,  with  a  stead- 
ily increasing  knowledge  of  the  pathology,  and  the 
consequently  more  rational  measures  of  treatment 
of  any  particular  disease,  must  eventually  result  in 
modifying  its  severity.  This  has  been  especially 
true  in  the  case  of  syphilis,  but  I  think  there  is  an- 
other more  powerful  influence  which  is  constantly 
manifesting  itself  in  the  case  of  contagious  diseases 
in  general,  viz  :  the  fact  that  disease  occurring  in 
individuals  of  one  generation  imparts  a  certain 
degree  of  immunity  to  their  descendants. 

A  very  interesting  article  bearing  upon  the  influ- 
ence of  heredity  and  natural  selection  in  modify- 


Lydston.  13 

ing  different  contagious  diseases,  has  been  recently 
written  by  Prof.  Lyman  of  this  city,  which  is  so 
logical  in  its  application  to  these  different  affections, 
that  I  think  we  may  apply  it  to  syphilis  as  well. 
The  doctor  cites  as  an  illustration  of  his  views,  the 
extraordinary  malignancy  of  measles  among  the 
natives  of  the  Sandwich  Islands,  a  few  years  since. 
These  people  were  never  affected  by  measles  until 
it  was  imported  by  the  whites,  and  consequently 
had  not  acquired  tolerance  of  the  disease. 
Although  the  population  of  these  islands  was  al- 
most decimated  at  the  time,  the  disease  has  steadily 
decreased  in  its  malignancy  ever  since.  Another 
illustration  cited,  is  the  peculiar  malignancy  of 
variola  among  the  negro  race.  Small-pox  was  un- 
known in  Africa  until  imported  by  Europeans,  and 
after  its  introduction  created  fearful  havoc  among 
the  natives.  It  has  not  yet  had  time  probably,  to 
become  very  markedly  modified,  but  a  steady  modi- 
fication is  to  be  expected.  When  an  epidemic  at- 
tacks a  community  it  attacks  those  susceptible  to  the 
disease,  and  modifies  their  organisms  in  such  a 
way  that  they  become  tolerant  of  future  attacks 
and  this  tolerance  they  transmit  in  a  measure  to 
their  descendants.  A  certain  number  of  individ- 
uals are  insusceptible  to  the  epidemic  influence,  and 
consequently  escape  the  disease.     This  insuscepti- 


14  Lecttjkes  on  Syphilis. 

bility  is  also  transmitted  to  the  next  generation. 
These  facts  illustrate  the  influence  of  heredity.  As 
1  have  stated,  a  certain  number  of  individuals  are 
primarily  insusceptible  to  the  disease  and  conse- 
quently escape  it,  while  those  individuals  who  are 
susceptible  to  it,  are  attacked,  with  a  fatal  result 
in  the  case  of  those  least  able  to  withstand  it. 
This  illustrates  the  influence  of  natural  selection. 
Applying  this  theory  to  syphilis,  we  may  readily 
see  that  the  disease  has  probably  destroyed  those 
subjects  least  able  to  resist  it,  and  that  the  im- 
munity from  the  disease  acquired  by  exposure  to 
its  influence  in  the  case  of  those  who  survived,  and 
the  primary  insusceptibility  of  a  certain  proportion 
of  individuals  have  been  transmitted  to  successive 
generations,  until  at  the  present  day  syphilis  is  a  com- 
paratively mild  afi'ection.  It  is  of  course  admitted 
that  the  insusceptibility  of  one  generation,  may 
depend  upon  the  inheritance  of  unequivocal  sj^philis 
from  the  parent  stock,  but  in  certain  instances  the 
transmitted  impression  is  very  attenuated. 

One  of  the  most  important  results  of  modern 
scientific  medical  research,  has  been  the  establish- 
ment of  the  duality  of  the  poisons  of  syphilis  and 
chancroid.  The  experiments  proving  this  have 
been  numerous  and  conclusive,  yet,  strange  as  it 
may  seem,  there  are  those  who  continue  to  believe 


Lydston.  15 

in  their  unity.  "^  This  diflference  in  opinion  has  re- 
sulted in  a  division  of  authorities  into  "unicists" 
and  '^dualists".  The  obscurity  which  formerly 
clouded  the  minds  of  surgical  authorities,  regard- 
ing the  venereal  diseases,  seems  very  remarkable 
to  us,  who  have  taken  advantage  of  their  errors. 
John  Hunter,  the  greatest  surgical  philosopher  of 
the  eighteenth  century,  believed  that  there  was  but 
one  venereal  disease,  and  that  a  constitutional 
affection.  He  believed  this,  because  he  had  pro- 
duced constitutional  syphilis  in  himself  by  inocu- 
lating his  arm  with  gonorrhoeal  virus.  He  labored 
under  this  delusion  until  the  day  of  his  death. 
Fully  half  a  century  later,  Ricord  demonstrated 
the  error  of  the  great  master,  but  he  himself  did 
not  recognize  tlie  difference  between  syphilis  and 
chancroid.  Fifty  years  later,  their  duality  was 
shown  by  Bass.ereau,  one  of  his  own  pupils.  I 
will  not  enter  into  a  lengthy  discussion  of  the 
different  authorities  and  methods  of  research  prov- 
ing the  duality  of  the  two  poisons,  for  the  fact  is 
generally  accepted ;  but  I  will  mention  a  few  facts 
bearing  upon  it.  We  can  all  fully  appreciate  one 
of  the  most  powerful  arguments  of  tho  unicists, 
viz:     "That  general  symptoms  frequently  follow 

*AinonK  those  who  adhere  to  the  old  theory,  may  be  mentioned 
Kaposi.  Many  prominent  English  surgeons  are  also  unicists,  hence 
the  confusion  of  terms  existing  in  most  English  works  upon  syphilis. 
With  them,  chancroid  is  also  and  erroneously  termed,  "local  syphilis," 


16  Lectures  on  Syphilis. 

an  apparently  non-indurated,  simple  sore,  but 
these  cases  are  simply  exceptions  to  a  well  estab- 
lished rule.  I  have  seen,  it  must  be  confessed, 
very  innocent  looking  sores  followed  by  secondary 
syphilis,  but  quite  rarely;  sufficiently  often  per- 
haps, to  render  me  cautious  in  the  matter  of  prog- 
nosis in  every  sore,  however  innocent  looking;  but 
not  often  enough  to  shake  my  own  convictions  as 
to  the  duality  of  syphilis  and  chancroid.  When 
chancroidal  poison  is  deposited  upon  a  raw  surface 
and  said  surface  is  cauterized  soon  afterAvards  no 
chancroid  results.  If,  however,  the  syphilitic  virus 
as  contained  in  the  secretion  of  a  chancre  or  syph- 
ilitic ulcer,  be  thus  inoculated  and  cauterized, 
syphilis  will  result,  as  a  rule.  Hill  cauterized  a 
ruptured  freenum  twelve  hours  after  intercourse, 
but  syphilis  developed  as  if  nothing  had  been  done. 
Fournier  cauterized  a  chancre  six  hours  after  its 
appearance,  but  syphilis  followed.  Excision  of  the 
primary  sore  has  been  practiced,  and  has  recently 
been  revived,  but  has  not  as  yet  been  proven  to 
prevent  the  development  of  syphilis.  It  has  seemed 
to  modify  it  in  certain  instances,  and  in  two 
personal  cases,  the  subsequent  secondary  manifes- 
tations were  very  mild.  This  proves  nothing 
however.  The  facts  that  I  have  given  you  are  suf- 
ficient in  themselves  to  prove  the  non-identity  of 


Lydstok.  ]  7 

syphilis  and  chancroid.  Syphilis  is  essentially 
constitutional,  (even  if  primarily  local)  while  chan- 
croid under  all  circumstance  is  a  purely  local  affec- 
tion. 

Attempts  at  the  inoculation  of  animals,  with 
syphilis  and  chancroid  have  shown  a  marked  differ- 
ence between  the  two  diseases.  Syphilis  is  not 
transmissible  to  the  lower  animals  while  chancroid 
is,  although  with  a  certain  amount  of  difficulty. 
Depaul,  however,  speaks  of  a  syphilitic  monkey, 
and  Martineau  has  recently  claimed  to  have  pro- 
duced a  hard  chancre  upon  the  penis  of  a  monkey. 
This  animal  was  afterwards  exhibited  to  the  French 
academy,  with  unequivocal  secondary  lesioils,  thus 
proving  the  communicability  of  syphilis  to  the 
monkey.  Neumann,  however,  in  some  recent  ex- 
periments upon  monkeys,  cats,  dogs,  rabbits,  and 
horses  has  failed  to  produce  syphilis.  If  the  state- 
ment that  syphilis  is  transmissible  to  the  monkey 
alone,  of  all  other  animals  be  true,  it  would  seem 
to  be  a  powerful  support  to  the  Darwinian  theory. 
The  course  of  syphilis  and  chancroid  is  sufficiently 
distinctive  in  typical  cases.  In  conclusion,  we 
might  ask  the  unicists  why,  if  the  poisons  of 
syphilis  and  chancroid  are  identical,  all  venereal 
sores  are  not  followed  by  constitutional  symptoms, 
when  allowed  to  run  their  natural  course  without 


18  Lectures  on  Syphilis. 

interference,  and  why  also,  all  sores  are  not  auto- 
inoculable  ? 

Syphilis  may  be  either  hereditary  or  acquh"ed, 
and  is  essentially  the  same  in  its  manifestations  in 
either  instance,  save  that,  as  we  shall  see  later  on, 
hereditary  syphilis  has  no  primary  stage.  Acquired 
syphilis  is  in  every  instance  due  to  confrontation 
and  inoculation  with  a  peculiar  poison  or  virus 
derived  originally  from  some  individual  suffering 
from  the  disease,  and  which  virus  is  contained  in 
either  the  secretion  of  a  syphilitic  lesion,  or  blood 
from  a  syphilitic  subject. 

The  length  of  time  necessary  for  the  absorption 
of  the  syphilitic  virus  after  the  inoculation  of  a 
healthy  tissue,  is  unknown,  but  it  is  unquestion- 
ably very  short,  although  no  direct  experiments 
have  been  made.  Abrasions  have  been  cauterized 
within  six  hours  after  suspicious  intercourse,  and 
yet  syphilis  has  developed.  Hill,  as  before  stated, 
relates  a  case  in  which  he  cauterized  a  ruptured 
fraenum  within  twelve  hours  after  exposure,  and  in 
which  syphilis  followed.  Numerous  experiments 
have  been  made  upon  poisons  bearing  an  analogy 
to  the  syphilitic  virus,  which  are  very  instructive 
and  allow  us  to  draw  some  conclusions  with  refer- 
ence to  sj'philis.  The  experiments  with  the  virus 
of  vaccinia  have  been  especially  interesting.     Seven 


Lydston.  19 

children  were  vaccinated  by  Martin  and  the  site  of 
the  operation  destroyed  by  Vienna  paste  at  periods 
varying  from  one  to  twenty-four  hours  thereafter. 
None  of  the  children  had  vaccinia;  but  all  but  one 
were  protected  from  variola  as  was  proven  by  the 
failure  to  inoculate  them  by  a  second  vaccination. 
Clerc  vaccinated  a  number  of  children,  destroying 
the  spot  with  nitrate  of  silver  one  hour  afterwards, 
but  vaccinia  was  not  prevented.  These  experi- 
ments suggest  that  possibly  vaccinia  consists  of 
two  essential  elements;  a  local  and  a  constitutional, 
which  permits  the  destruction  of  the  morbid  im- 
pression causing  the  local  process  without  any 
modification  of  the  constitutional  manifestations  of 
the  virus.  Whether  the  same  view  may  be  taken 
of  syphilis,  remains  to  be  seen.  In  France,  numer- 
ous experiments  upon  animals  have  been  made  by 
different  surgeons,  with  the  poison  of  glanders. 
The  seat  of  the  inoculation  has  been  excised  within 
one  minute  after  the  introduction  of  the  virus,  yet 
glanders  was  not  prevented.  It  is  probable  that 
the  virus  of  syphilis  is  not  absorbed  as  quickly  as 
some  other  poisons,  but  reasoning  from  the  experi- 
ments cited,  the  period  required  must  be  very  short. 
Unlike  chancroid,  true  syphilis  is  very  rarely 
contracted  twice.  Second  attacks,  however,  have 
been  reported.      Diday  has   collected  twenty-five 


20  Lectukes  on  Syphilis. 

such  cases,  twenty  of  which  were  in  his  own  prac- 
tice. These  cases  are  especially  interesting,  both 
from  their  rarity  and  the  fact  that  they  most  con- 
clusively prove  the  curability  of  syphilis,  for  were 
the  disease  not  curable,  a  second  attack  would  be 
impossible.  A  few  of  Diday's  cases  were  con- 
tracted during  the  existence  of  tertiary  manifesta- 
tions of  the  previous  attack,  and  this  too  is  an  im- 
portant fact  as  showing  that  the  ' '  tertiary  syph- 
ilides"  are  not  syphilitic  at  all,  but  are  simply 
non-transmissible  sequela?.  The  longer  the  interval 
beween  the  first  and  second  attacks,  the  more  severe 
the  latter  is  likely  to  be,  but  in  the  majority  of 
cases  the  second  attack  consists  in  the  primary 
symptoms  alone  without  any  further  manifestations 
of  the  disease.  This  of  course,  lends  color  to  our 
doubts  as  to  the  accuracy  of  the  diagnosis  in  dif- 
ferent cases.  I  have  seen  in  my  own  experience 
two  cases  which  I  believe  to  have  been  a  second 
attack  of  ti'ue  syphilis,  the  data  of  which  I  am  un- 
fortunately unable  to  present  to  you.  In  each 
case  there  had  been  a  previous  attack  of  true  syph- 
ilis which  had  been  diagnosed  by  two  prominent 
gentlemen,  one  of  whom  was  no  less  an  authority 
than  the  late  Dr.  Bumstead.  There  is  no  doubt  in 
my  own  mind  as  to  the  condition  for  which  I  treated 
these  men,  and  I  can  hardly  question  the  accuracy 


Lydston.  21 

of  the  first  diagnosis.  There  are  several  sources 
of  fallacy  in  determining  the  existence  of  a  second 
attack  of  syphilis,  which  must  be  remembered. 
1st. — ^In  the  first  place  you  may  have  some  coinci- 
dent eruption  accompanying  chancroid.  2nd. — 
Ecthyma  may  be  mistaken  for  true  syphilis,  and,  if 
following  a  genuine  attack,  be  cited  as  a  case  of 
second  infection,  or  the  first  attack  may  have  been 
ecthyma,  and  the  second  true  syphilis.  3rd. — A 
chancroid  or  mucous  patch  may  become  the  seat  of 
such  marked  inflammatory  induration  that  it  is 
mistaken  for  true  chancre.  4th. — A  tertiary  gum- 
my ulcer  may  be  taken  for  hard  chancre. 

I  have  already  mentioned  the  non-transmissi- 
bility  of  syphilis  to  the  lower  animals  and  cited 
the  exception  of  the  monkey  as  claimed  by  Mar- 
tineau.  It  is,  as  we  have  already  seen,  a  demon- 
strable fact  that  syphilis  difiers  markedly  from 
chancroid  in  this  respect.  But  it  is  claimed  that 
animals  also  have  venereal  disease,  or  afiections 
contracted  only  through  sexual  intercourse.  There 
is  an  afiection  somewhat  analogous  to  syphilis  which 
afiects  horses  and  asses.  This  disease,  termed  the 
doury,  is  only  transmitted  during  sexual  inter- 
course. It  develops  after  an  incubation  of  four  to 
six  weeks,  with  the  phenomena  of  fever  and  cut- 
aneous tumors,  and  sometimes  the  mucous  mem- 


22  Lectures  on  Syphilis. 

branes,  eyes,  and  bones  may  undergo  pathological 
changes,  atrophy  or  paralysis  sometimes  following 
in  extreme  cases.  The  disease  lasts  from  a  couple 
of  months  to  three  years,  and  is  not  auto-inoculable. 
A  local  contagious  venereal  disease  is  also  seen  in 
these  animals  according  to  Lancereaux.  Inasmuch 
as  these  affections  differ  from  syphilis  in  a  marked 
degree,  and  particularly  in  the  matter  of  inocula- 
bility,  their  analogy  to  that  disease  is  probably  very 
slight.  It  would  seem  that  mankind  has  the  sole 
monopoly  of  the  doubtful  luxury  of  syphilis. 

After  the  poison  of  syphilis  has  been  absorbed, 
a  certain  period  elapses  before  its  morbid  effects 
become  manifest.  This  period  is  known  as  the 
stage  of  incubation,  and  lasts  upon  the  average 
about  twenty-one  days,  but  varying  considerably 
from  this  in  different  cases.  Fournier  relates  a  case 
in  which  the  period  was  seventy-five  days,  Guerin, 
one  of  seventy-one  days,  and  I  have  myself  noted 
one  case  of  seventy  days.  Instead  of  being  pro- 
longed the  period  may  be  shorter  than  usual,  thus 
Hammond  relates  one  of  three  days,  and  -  the  late 
Dr.  Nott,  of  New  York,  reported  his  own  case  as 
developing  within  twenty-four  hours  after  wound- 
ing his  finger  in  operating  upon  a  syphilitic  subject. 
Dr.  R.  W.  Taylor,  of  New  York,  reports  one  case 
in  which  the  initial  lesion  appeared  upon  the  second 


Lydston.  23 

day,  induration  upon  the  fourth  day  and  general 
symptoms  during  the  sixth  week,  and  another 
in  which  the  chancre  appeared  at  the  end  of  the 
first,  and  the  general  symptoms  during  the  fifth 
week.  Practically,  gentlemen,  we  may  accept  the 
statement  that  as  a  rule,  true  chancre  does  not  ap- 
pear before  the  tenth  day.  Any  sore  appearing 
prior  to  that  time,  is  probably  chancroid,  while  any 
appearing  later,  is  quite  likely  to  be  true  chancre. 
This  is  a  useful  practical  rule  to  remember,  although 
it  must  be  confessed  that  it  is  often  of  little  service 
in  diagnosis,  inasmuch  as  the  majority  of  individuals 
contracting  venereal  disease  are  in  the  habit  of  pro- 
miscuous intercourse,  and  therefore  absolutely  un- 
able to  determine  which  of  their  numerous  adven- 
tures has  been  the  unlucky  one.  Whenever  the  in- 
duration of  a  sore  is  characteristic,  we  are  of  course, 
in  no  wise  dependent  upon  the  period  of  incubation 
for  a  diagnosis. 

Induration  of  a  peculiar  type  is  the  distinguish- 
ing feature  of  a  syphilitic  chancre  and  the  manner 
of  its  formation  and  its  histological  characters  are 
consequently  a  matter  of  considerable  importance. 
This  brings  us  to  the  consideration  of  the  patholog- 
ical changes  of  syphilis,  or  as  Otis  terms  it,  the 
'  'physiological  pathology"  of  the  disease.  We  ought 
naturally  to  begin  our  study  of  the  subject,  with 


24  Lectures  on  Syphilis. 

the  consideration  of  the  primary  or  initial  lesion, 
and  beginning  at  the  seat  of  infection  we  have  a 
number  of  quite  important  changes.  We  have  first 
the  absorption  of  a  peculiar  morbific  principle  or 
"virus,"  which  although  unknown  as  an  entity  is 
only  too  plainly  manifest  in  its  pathological  efiects.^ 
The  most  probable  view  of  the  nature  of  this  virus 
is,  that  it  consists  of  a  degraded  infectious  cell  of 
very  minute  proportions.  However  lacking  we 
may  be  in  positive  knowledge  of  its  nature,  we  at 
least  have  tolerably  definite  views  of  the  manner  of 
its  action.  The  first  effect  of  the  syphilitic  virus, 
is  the  production  of  a  gradually  increasing  accum- 
ulation of  lymph  or  white  blood  cells  at  the  site  of 
inoculation,  which  is  brought  about  by  a  modifica- 
tion of  the  normal  leucocytes  and  connective  tissue 
elements,  by  what  we  will  term  the  '  'syphilitic  ger- 
minal cell."  This  modification  probably  begins 
immediately  after  the  absorption  of  the  poison,  but 
is  more  or  less  gradual  in  manifesting  itself,  hence 
we  have  a  certain  period  elapsing  before  evidences 
of  its  action  are  exhibited.  These  accumulated 
cells,  previously  normal,  contain  the  "germs"  of 
the  syphilitic  poison,  and  their  constitution  is  now 

*I  regard  the  bacillus  claimed  to  have  been  discovered  by 
Lustgarten,  as  yet  to  be  proven.  In  any  event,  its  existence  does  not 
modify  the  pathology  of  the  disease,  for  Lustgarten  claims  that  it  acts 
by  incorporating  itself  with  the  white  corpuscles. 


Lydston.  25 

greatly  modified.  They  have  become  larger,  more 
granular,  and  contain  numerous  nuclei,  are  infec- 
tious, and  have  their  powers  of  proliferation  and 
amoeboid  movement  exaggerated.  In  addition  they 
present  a  marked  tendency  to  retrograde  metamor 
phosis.  When  removed  from  their  original  situa- 
tion to  the  tissues  of  a  healthy  individual,  these 
cells,  by  virtue  of  their  infectiousness,  produce 
changes  in  the  normal  leucocytes  in  their  new  en- 
vironment, exciting  rapid  proliferation  in  them,  as 
well  as  undergoing  rapid  changes  themselves. 
Now,  how  does  the  "syphilitic  germinal  cell"  act 
upon  the  normal  leucocyte?  It  is  claimed  that 
through  degradation  the  syphilitic  germinal  cell  may 
be  but  1-100,000  of  an  inch  in  diameter,  being  per- 
haps merely  one  of  the  nuclei  of  some  infected  and 
degraded  leucocyte,  but  retaining  all  its  morbid 
powers  of  proliferation  and  amoeboid  activity,  the 
latter  being  especially  marked.  As  the  white  blood 
cell  or  normal  leucocyte  is  1-2,500  of  an  inch  in  dia- 
meter, it  is  obvious  that  by  virtue  of  the  peculiar 
affinity  of  the  syphilitic  germinal  cell  for  it,  the  two 
may  become  incorporated,  with  the  result  of  the 
modification  of  the  leucocyte  which  I  have  des- 
cribed. ^ 

*By  supposing  an  incorporation  of  the  bacillus  of  Lustgarten,  witfit 
the  leucocyte,  insteid  of  the  hypothetical  cell  described,  we  can  at 
once  harmonize  the  bacillar  theory  of  the  origin  of  syphilis,  with  its 
"physiological  pathology." 


26  Lectukes  on  Syphilis. 

Now  gentlemen,  I  wish  to  impress  upon  your 
minds  a  thorough  understanding  of  the  nature 
of  the  modified  cell  which  I  have  described,  for  a 
knowledge  of  this  cell  is  the  ke^'  to  the  study  of 
syphilis.  Just  as  the  leucocyte  is  the  primordial 
cell  in  the  normal  physiological  processes  of  growth, 
so  is  it  the  basis  of  all  pathological  processes, — 
and  particularly  those  of  syphilis — when  it  is  mod- 
fied  in  the  manner  peculiar  to  the  particular  morbid 
change  in  the  tissues.  Taking  as  our  point  of  de- 
parture, the  initial  lesion  of  syphilis,  we  have  a 
localized  proliferation  of  this  very  cell,  and  follow- 
ing it  in  its  course,  we  have  thickening  of  the 
lymphatic  vessels  and  enlargement  of  the  lymphatic 
glands,  produced  by  this  same  cell  accumulation. 
The  cell  now  travels  on,  enters  the  receptaculum 
chyli,  and  is  finally  emptied  into  the  circulation  by 
the  thoracic  duct,  to  be  then  driven  to  the  super- 
fices  of  the  body  with  the  general  blood  current. 
In  the  different  tissues  we  now  have  various  secon- 
dary phenomena,  and  we  will  briefly  consider  some 
of  them.  'General  enlargement  of  the  lymphatic 
glands  occurs,  as  a  result  of  the  proliferation  of  the 
cells  carried  to  them  by  the  blood,  and  an  accumu- 
lation of  infected  germinal  material  collected  by 
the  absorbents  from  the  superfices.  Engorgement 
of  the  fauces  and  pharynx  now  occurs  and  is  due 
to  a  "localized  cell  accumulation"  in  the  rich  net- 


Lydston.  27 

work  of  lymphatics,  which  as  we  shall  see  later  on, 
is  a  marked  feature  of  the  anatomy  of  the  fauces, 
tonsils  and  pharynx.  Mucous  patches  are  likely 
to  occur,  and  are  simply  papules  upon  moist  mucous 
surfaces,  due  to  a  circumscribed  collection  of  the 
characteristic  cells.  The  same  description  will  ap- 
ply to  the  true  papule  upon  the  integumentary  sur- 
faces. This  papule  may  have  an  excessive  accum- 
ulation of  cells,  and  become  a  tubercle,  or,  from 
pressure  upon  and  interference  with  the  nutrition 
of,  the  normal  tissue  elements  by  the  cells,  in  com- 
bination with  their  own  tendency  to  retrograde 
metamorphosis,  we  may  have  a  pustule  formed  which 
may  break  and  result  in  ulceration.  Nodes  or  pe- 
culiar periosteal  swellings  occurring  in  syphilis,  are 
simply  collections  of  proliferating  syphilitic  cells. 
You  will  notice  that  I  have  not  mentioned  syphil- 
itic roseola,  and  you  perhaps  fail  to  see  how  we  are 
going  to  explain  it,  but  by  a  little  roundabout 
pursuit,  I  think  we  can  again  catch  our  cell  at  work, 
not  this  time  by  a  localized  accumulation,  but  pro- 
ducing the  syphilitic  roseola  by  its  effect  upon  the 
sympathetic  system,  which  becomes  manifest  in 
capillary  dilatation  and  stasis.  I  think  I  have 
shown  you  the  potency  of  the  syphilitic  cell  in  the 
pathology  of  syphilis,  and  I  will  next  endeavor  to 
demonstrate  the  therapeutic  importance  of  a  thor- 
ough knowledge  of  its  properties  and  actions. 


Lecture  II. 

Initiatory  period. — Importance  of  a  knowledge  of  the  properties  of  the 
syphilitic  cell  in  the  therapeusis  of  the  disease. — Anatomy  and  his- 
tology of  the  chancre  and  of  syphilitic  lymphitis  and  adenitis,  so- 
called.— Condition  of  glands  in  general  adenopathy.— Definition  of 
the  initiatory  period. — Varieties  of  induration  of  chancre. — Cause  of 
chancrous  "  ulcers."— Extent  of  induration. — Duration  of  i  dura- 
tion.— Character  of  chancrous  secretion. — Cicatrix  of  chancre.— 
Chancrous  secretion  not  auto-inoculable. — Course  of  syphilis  in 
hetero-inoculation. — Vaccinal  syphilis.— Multiple  chancre. — Poison- 
bearing  secretions  of  syphilis. — Necessity  for  the  presence  of  the 
syphilitic  cell  in  contagious  secretioas  of  syphilis. 

Gentlemen: — In  my  last  lecture,  I  endeavored 
to  demonstrate  in  a  general  way,  the  pathological 
importance  of  the  syphilitic  cell,  by  following 
it  in  its  tour  of  mischief,  and  noting  briefly  its 
results.  Now,  as  I  have  already  stated,  this  cell 
is  not  only  important  as  regards  the  pathology  of 
syphilis,  but  a  knowledge  of  its  properties  and 
actions,  is  absolutely  indispensible  to  the  intelli- 
gent application  of  remedies  to  the  cure  of  the 
disease.  We  will  premise  that  the  natural  course 
of  the  syphilitic  cell  is  to  accumulate  in,  and  ob- 
struct, various  tissues,  thereby  forming  neoplastic 
masses  very  similar  in  structure  to  inflammatory 
neoplasia,  and  finally  to  undergo  retrograde  meta- 
morphosis and  elimination,  which  result  eventually 
in  spontaneous  cure  of  the  disease.^  The  danger 
of  permanent  injury  to  the  tissues  is  proportionate 

*  Vide  Otis,  "Physiology  and  Pathology  of  SyphUis." 


30  Lectures  on  Syphilis. 

to  the  amount  of  the  accumulated  cells,  and  the 
length  of  time  they  remain  in  contact  with  the  nor- 
mal tissues,  thereby  producing  secondary  changes 
in  their  structure.  Understanding  these  facts,  we 
most  naturally  seek  for  remedies,  the  administra- 
tion of  which  tends  to  remove  new  formations  and 
cell  accumulations,  by  favoring  or  directly  inducing 
retrograde  metamorphosis  in,  and  elimination  of, 
such  morbid  material.  These  remedies  will  receive 
attention  later  on,  as  I  now  wish  merely  to  impress 
you  with  the  importance  of  an  accurate  knowledge 
of  the  pathology  of  syphilis  in  explaining  the  ra- 
tionale of  their  action.  You  will  readily  appreciate 
the  fact  that  a  careful  study  of  the  characteristic 
cell  which  constitutes  the  basis  of  all  syphilitic 
processes,  will  enable  you  to  thoroughly  under- 
stand the  disease  in  all  its  manifold  forms. 

Now  let  us  see  how  this  little  cell  which  I  have 
already  described  to  you,  brings  about  the  various 
changes  characteristic  of  syphilis.  As  we  have 
seen,  the  first  manifestation  of  syphilis  is  a  peculiar 
lesion  characterized  by  induration.  This  is  due  to 
a  localized  accumulation  of  cells,  which  are  infil- 
trated in  the  meshes  of  the  connective  tissue,  and 
the  adventitia  of  the  blood  vessels,  forming  a  cir- 
cumscribed mass.  The  cells  vary  somewhat  in 
their  general  characteristics,  those  in  the  coats  of 


Lydston.  31 

the  vessels  being  either  round,  spindle-shaped,  or 
branched,  but  the  bulk  of  the  mass  consists  of  the 
characteristic  round,  multinucleated  granular  cell, 
which  we  have  already  known  to  be  a  modified 
leucocyte.  These  changes  are  very  similar  to  those 
seen  in  simple  dermatitis  excepting  that  there  is  no 
serous  exudate,  the  induration  being  consequently 
dry  and  hard.  This  absence  of  fluid  is  due  to  the 
thickened  walls  and  contracted  lumen  of  the  vessels, 
which  renders  it  difficult  for  the  serum  to  exude 
from  them.  For  the  same  reason,  there  is  anaemia 
and  innutrition  of  the  neoplasm."^ 

The  small  blood  vessels  throughout  the  body  are 
surrounded  by  "peri-vascular lymph  spaces",  audit 
is  even  claimed  that  the  tunica  adventitia  of  the 
smaller  vessels  is  really  a  part  of  the  lymphatic 
system.  You  may  thus  readily  see  how  intimately 
the  blood  and  lymphatic  vessels  are  associated. 
There  is  a  constant  current  from  the  tissues  to  the 
lymphatics,  and  it  is  very  evident  that  after  a  time 
the  morbid  cells  about  the  neoplasm  must  neces- 
sarily as  they  extend,  enter  the  lymphatic  circula- 
tion. This  explains  the  circumscription  of  the 
induration,  the  cells,  after  a  certain  time,  being 
removed  as  fast  as  formed,  thus  limiting  their  local 
development.  We  will  now  assume  the  ground 
that  the  first  manifestations  of  syphilis  are  purely 

*  Vide  Besiadecki. 


32  Lectures  on  Syphilis. 

local,  and  see  if  we  can  give  a  logical  explanation 
of  them . 

In  a  few  days  after  the  development  of  the  initial 
induration  of  syphilis,  or  chancre,  the  lymphatic 
vessels  leading  from  the  infected  surface  begin  to 
enlarge  and  become  hardened,  feeling  often  like 
pieces  of  pencil  or  wire  under  the  skin.  This  is 
due  to  a  low  grade  of  inflammatory  change,  asoci- 
ated  with  a  localized  cell  proliferation.  Now,  it 
may  seem  strange  to  you  that  this  alteration  in  the 
lymphatics  does  not  occur  immediately  after  the 
appearance  of  the  chancre,  instead  of  after  an  in- 
terval of  some  days,  but  it  is  explained  by  the  fact 
that  the  cell  accumulation  constituting  the  chancre 
must  extend  until  a  lymphatic  vessel  of  some  size 
is  reached  before  the  cells  can  enter  the  lymphatic 
current,  the  absorptive  power  of  the  small  lymphat- 
ics being  annulled  by  pressure  and  local  irritation. 
A  strong  argument  in  favor  of  this  view  is  the  fact 
that  the  period  of  incubation  is  shortest,  and  the 
chancre  smallest,  in  those  parts  most  richly  sup- 
plied with  lymphatics.  There  is  also  less  connec- 
tive tissue  proliferation  in  such  localities.  An  ex- 
ample of  this,  is  chancre  developed  beside  the 
frsenum  prseputii.  The  changes  in  the  lymphatic 
vessels  gradually  extend  along  their  course,  the 
movbid  and  infectious  cells  meanwhile  travelling 


Lydston.  38 

slowly  on  in  the  lymph  current,  and  finally  reach- 
ing the  lymphatic  glands.  Enlargement  of  the 
glands  now  occurs,  those  nearest  the  primary  sore 
being  the  first  to  enlarge,  but  general  syphilitic 
adenopathy  eventually  occurring,  and  each  gland, 
however  small,  becoming  consequently  a  depot  for 
the  production,  storing  up,  and  finally  the  distri- 
bution of  the  abnormal  cell  growth.  Each  lym- 
phatic gland,  as  the  proliferation  of  cells  goes  on 
in  its  substance,  becomes  hard  and  woody  to  the 
touch,  being  nothing  more  or  less  than  a  neoplastic 
growth  precisely  identical  with  the  chancre  itself, 
and  presenting  the  same  microscopical  characters. 
The  changes  at  the  site  of  infection,  and  in  the 
lymphatic  glands  first  involved,  may  be  termed 
the  ^'initiatory  period"  of  syphilis,  and  up  to  this 
time  no  blood  changes  have  become  manifest,  all 
the  changes  being  apparently  local.  I  will  now 
leave  the  consideration  of  the  progress  of  the  syph- 
ilitic cell,  inasmuch  as  we  have  traced  it  to  its  des- 
tination in  the  lymphatic  glands,  and  allow  it  to 
remain  undisturbed  until  we  have  given  a  little 
more  attention  to  the  initial  lesion,  and  other  im- 
portant points  in  the  study  of  syphilis. 

In  the  first  place  the  initial  induration  may  pre- 
sent itself  under  several  difierent  forms,  a  study  of 
which  will  be  quite  profitable. 


34  Lbctubes  on  Syphilis. 

1st.  The  first  form  is  what  is  termed  the  parch- 
ment induration,  which  usually  underlies  an  ulcer- 
ation, and  may  escape  notice  unless  carefully 
sought  for  by  pinching  up  the  lesion  with  the 
thumb  and  finger,  in  such  a  manner  as  to  press 
lightly  upon  its  edges  without  bending  it.  This  is 
the  commonest  form  according  to  some  authorities, 
and  I  have  found  it  so  in  hospital  practice.  The 
last  four  or  five  cases  that  I  have  met  in  private 
practice  have,  however,  been  beautiful  examples 
of  the  Hunterian  chancre. 

2d.  The  induration  may  be  somewhat  like  a  split 
pea  beneath  the  skin,  its  convex  surface  being  capped 
by  the  ulceration.  This  induration  is  plainly 
marked,  and  freely  movable  with  a  feel  like  wood 
or  bone,  or  perhaps  more  nearly  like  cartilage. 

3d.  The  induration  may  be  quite  extensive  and 
extend  beyond  the  bounds  of  the  ulceration,  reach- 
ing very  often,  the  size  of  a  chestnut  or  almond. 
There  may  or  may  not  be  ulceration.  When  an 
induration  of  this  description  is  ulcerated,  its  con- 
vexity is  sometimes  capped  with  a  funnel-shaped 
ulcer,  the  whole  constituting  the  so-called  Hunter- 
ian chancre.  We  meet  with  many  cases  in  which 
there  is  merely  a  hard  purplish  lump  with  no  ulcer- 
ation, or  at  most  a  very  superficial  erosion  capping 
the  induration. 


Ltdston.  85 

4th.  There  is  a  variety  of  the  parchment  indu- 
ration sometimes  seen,  which  is  especially  apt  to 
escape  attention,  so  insignificant  does  it  seem.  It 
consists  in  a  very  superficial  cell  infiltration,  pre- 
senting a  very  slight  induration  when  lightly 
pressed  upon.  In  appearance  it  is  a  slightly 
brownish  patch  covered  by  very  fine  scales,  not 
unlike  a  minute  patch  of  psoriasis."^ 

The  occurrence  of  ulceration  in  the  chancre  is 
quite  important,  and  is  explicable  aside  from  the 
various  sources  of  irritation  which  may  exist  as  an 
exciting  cause,  by  the  histological  characters  of 
the  lesion.  As  we  have  seen,  the  chancre  consists 
of  a  localized  cell  accumulation,  which  not  only 
presses  upon  the  capillaries,  but  actually  invades 
their  walls,  thus  causing  a  diminution  of  the  blood 
supply  and  a  relative  anaemia  and  innutrition  of 
the  neoplasm  and  the  tissue  involved  by  it.  This 
innutrition  gives  rise  to  molecular  disintegration 
of  the  superficial  layers  of  the  lesion,  which  break 
down  and  form  an  ulcerated  surface.  This  process 
is  termed  by  Besiadecki,  "ansemia  of  tissue,"  and 
by  Yirchow,  "necrobiosis".  The  secretion  of  this 
ulcer  is  scanty  when  unirritated,  for  the  same 
reason  ^iven  for  the  hardness  and  dryness  of  the 
induration,  viz.,    absence   of  serous   efiusion.     It 

*  Called  by  Otis,  superficial  induration  in  the  form  of  the  "dry- 
scaling  patch," 


36  Lectures  on  Syphilis. 

contains,   however,    the   syphilitic   germinal   cell, 
and  is  highly  contagious. 

The  induration  of  chancre  is  variable  in  its  ex- 
tent according  to  the  tissues  in  which  it  is  situated, 
and  is  proportionate  within  certain  limits  to  the 
extent  of  surface  primarily  infected,  e.  g.,  when 
a  cut  or  abrasion  is  inoculated  with  the  syphilitic 
poison,  the  resulting  chancre  is  likely  to  assume 
the  size  and  conformation  of  the  traumatic  lesion. 
Chancres  of  the  nipple,  lips,  skin,  and  behind  the 
corona  glandis  are  likely  to  be  extensively  indu- 
rated. In  such  spongy  tissues  as  the  glans  penis, 
the  induration  is  apt  to  be  very  slight.  The  spar- 
sit}^  of  connective  tissue  beneath  the  mucous  mem- 
brane, and  the  extreme  tenuity  of  the  mucous 
membrane  itself,  will  perhaps  serve  to  explain  the 
latter  fact.  In  quite  rare  cases  of  chancre,  or  ap- 
parently simple  lesions  followed  by  constitutional 
syphilis,  induration  appears  to  be  entirely  absent, 
but  this  is  perhaps  due  to  the  fact  that  it  has  been 
overlooked  through  inattention,  or  its  co-existence 
with  chancroid,  or  it  is  so  slight  as  not  to  attract 
attention.  After  a  chancre  becomes  phagedenic, 
induration  at  once  disappears.  In  other  instances 
a  sore  may  not  be  watched  long  enough,  or  indura- 
tion appears  and  disappears  within  a  very  short 
space  of  time. 


Lydston.  37 

In  simple  chancre  the  induration  most  generally 
precedes  the  ulceration,  but  it  often  follows  it, 
coming  on  in  the  course  of  the  first  week.  This  is 
usually  due  to  infection  with  some  local  irritant, 
chancroidal  or  otherwise,  simultaneously  with  the 
syphilitic  infection,  and  is  the  invariable  course  of 
mixed  sores,  and  it  is  highly  probable  that  the  ma- 
jority of  cases  in  which  induration  follows,  instead 
of  preceding,  ulceration,  are  primarily  either  chan- 
croid, or  simple  exulceration.  In  fact  I  am  inclined 
to  believe  that  this  is  always  the  case,  and  we  may 
accept  the  rule  that,  syphilitic  ulceration  is  always 
due  to  '''' necrobiosis'''  or  ^^anoemia  of  tissue''^  unless 
there  exists  some  source  of  irritation^  simple  or 
specific.  I  emphasize  this  more  particularly  be- 
cause this  method  of  ulceration  is  the  type  of  tissue 
destruction,  seen  throughout  the  entire  course  of 
syphilis,  and  I  wish  you  to  remember  ulceration  as 
in  certain  instances  the  result  of  simple  innutrition 
from  pressure  and  tissue  obstruction.  It  matters 
not  whether  the  molecular  disintegration  produced 
by  the  syphilitic  neoplasia,  or  occurring  within 
them,  results  in  an  open  lesion,  as  an  ulcer,  or 
occurs  in  the  form  of  a  softening  node  or  a  pustule, 
the  process  is  the  same  throughout.  If  you  will 
but  remember  this  fact,  gentlemen,  you  will  have 
no  difficulty  in  comprehending  the  pathology  of 
syphilis. 


38  Lectures  on  Syphilis. 

Induration  of  a  chancre  may  be  very  transitory, 
and  as  I  have  already  indicated,  may  disappear  so 
rapidly  as  to  be  overlooked.  It  has  been  observed 
to  last  only  twelve  days,  but  such  cases  are  very 
exceptional,  the  ordinary  duration  being  from  one 
to  three  months,  but  in  rare  cases  lasting  for  some 
years.  The  discharge  of  a  syphilitic  chancre  is 
very  scanty  and  sero-purulent,  for  reasons  already 
given,  and  retains  these  characters  throughout, 
unless  the  sore  becomes  inflamed,  in  which  case  it 
becomes  profuse  and  purulent,  and  perhaps  bloody. 
Some  cases  of  chancre  appear  to  exhibit  a  marked 
tendency  to  bleed,  and  I  have  observed  a  number 
of  cases  in  which  this  symptom  was  quite  persistent 
and  recurred  upon  the  slightest  manipulation  of 
the  sore."^  The  scar  left  by  chancre,  depends  upon 
the  depth  of  the  ulceration,  and  in  many  cases  noth- 
ing is  left  but  a  livid  or  ham-colored  spot,  which 
perhaps  becomes  of  a  coppery  hue  later  on,  and 
finally  fades  completely. 

I  have  already  mentioned  the  fact  that  syphilis  is 
not  auto-inoculable,  this  being  a  very  important 
point  in  the  diflferentiation  of  chancre  and  chan- 
croid. Many  attempts  have  been  made  with  syph- 
ilitic secretions,  and  especially  the  secretion  of  the 
chancrous  ulcer,  but  auto-inoculation  has  thus  far 
been  found  impossible  as  a  rule.     When  a  chancre 

*The  so-called  "hemorrhagic  chancre." 


Lydston.  39 

is  inflamed  and  secreting  profusely,  its  secretion 
will  produce  a  pustule  if  auto-inoculated,  acting 
in  precisely  the  same  manner  as  any  other  irritant. 
This  pustule  may  be  followed  by  ulceration,  but 
never  by  hard  chancre.  There  is  a  question  in  my 
own  mind,  whether,  if  blood  be  drawn  from  an  in- 
itial lesion  before  ulceration  occurs,  i.  e.  early 
enough  in  the  course  of  chancre,  it  may  not  be  ca- 
pable of  inoculating  the  individual  possessing  the 
lesion.  This  doubt  is  due  to  my  inclination  to  the 
belief  that  syphilis  is  primarily  local,  and  has  been 
enhanced  by  a  recent  case  which  I  have  observed. 
I  excised  a  large  indurated  chancre  with  a  slight 
surmounting  ulceration,  from  the  penis  of  one  of 
my  patients,  taking  the  precaution  to  wait  until  the 
process  was  apparently  stationary,  and  the  chancre 
fully  developed.  The  ulcer  was  first  cauterized  to 
prevent  contamination  of  the  wound  by  its  secre- 
tion, after  which  the  indurated  tissue  was  thoroughly 
excised,  the  incisions  being  made  well  beyond  the 
borders  of  the  diseased  tissues.  An  irregular 
wound  was  left,  which  was  closed  with  several  cat- 
gut sutures.  On  the  second  day,  the  wound  had 
united  and  everything  looked  well,  but  on  the 
fourth  day,  induration  of  the  edges  of  the  wound 
began,  and  in  a  few  days  had  involved  their  entire 
extent,  and  the  surrounding  tissues  for  some  little 


40  Lectures  on  Syphilis. 

distance,  and  finally  attaining  the  size  of  an  almond, 
being  at  least  twice  the  size  of  the  chancre  excised. 
Now  all  this  looked  very  singular,  as  1  had  removed 
all  the  indurated  tissue,  and  if  constitutional  syph- 
ilis already  existed,  no  infection  of  the  cut  surfaces 
should  have  occurred.  As  I  can  see  no  other  ex- 
planation, I  believe  that  the  infection  took  place 
through  the  medium  of  the  blood  which  escaped 
from  the  chancre.  It  is  certainly  peculiar  that  the 
resulting  chancre  should  be  proportionate  in  extent 
to  the  cut  surfaces,  and  of  a  similar  shape.  But 
one  swallow  does  not  make  a  summer,  so  we  will 
have  to  accept  the  diction  that  syphilis  is  not  aato- 
inoculable. 

The  course  of  syphilis  in  hetero-inoculation  is  in- 
teresting. When  any  secretion  containing  the 
syphilitic  cells,  such  as  discharge  from  a  syphilitic 
chancre  or  mucous  patch,  or  blood  from  a  syphilitic 
subject,  is  inoculated  upon  a  healthy  individual, 
there  may  be  a  small  pustule  following,  just  as  a 
fester  may  form  from  the  prick  of  a  clean  lancet, 
but  this  only  lasts  a  few  days,  and  is  generally  ab- 
sent, there  being  nothing  to  indicate  the  site  of  the 
inoculation  unless  perhaps  a  speck  of  dried  blood, 
until  after  a  period  of  from  ten  to  forty  days,  when  an 
indurated  papule  appears.  This  becomes  ulcerated 
most  likely,  but  may  not  do  so;  the  neighboring  lym- 


Lydston.  41 

phatics  become  enlai-ged,  and  general  syphilis  fol- 
lows. In  cases  of  vaccinal  syphilis,  or  syphilis  ac- 
quired accidentally  in  the  operation  of  vaccination,  a 
somewhat  different  course  is  followed.  The  incu- 
bation period  of  vaccinia  expires  first,  the  charac- 
teristic vesicle  appearing  and  running  its  usual 
course.  After  a  time,  however,  the  vaccine  vesicle 
becomes  an  ecthymatous  ulcer  with  an  indurated 
base,  or  induration  appears  and  runs  its  course 
without  ulceration.  When  a  subject  already  syph- 
ilitic is  vaccinated,  we  are  likely  to  have  a  char- 
acteristic secondary  syphilitic  ulcer  resulting,  after 
the  typical  vaccinal  vesicles  have  first  formed. 
Such  an  instance  recently  occurred  in  one  of  my 
own  patients,  although  he  was  under  the  influence 
of  mercury  at  the  time.  A  very  important  source 
of  error  with  regard  to  vaccinal  syphilis,  and  one 
which  you  should  always  bear  in  mind,  is  that  the 
local  and  constitutional  disturbance  produced  by 
vaccinia,  is  liable  to  develop  latent  syphilis,  whether 
hereditary  or  acquired,  and  that  the  vaccinator  will 
probably  get  the  credit  of  having  inoculated  the 
disease.  In  such  cases  you  will  usually  observe  a 
more  or  less  general  eruption  starting  in  the  vicin- 
ity of  the  sore,  instead  of  the  typical  period  of  in- 
cubation, followed  by  typical  induration  and  after 
a  variable  interval,  by  glandular  enlargement  and 
general  syphilis. 


4'i  Lectures  on  Syphilis. 

^VTien  the  syphilitic  poison  is  inoculated  upon  a 
number  of  raw  surfaces  simultaneously,  or  after  a 
few  days'  interval,  chancre  appears  usually  at  each 
point  at  about  the  same  time.  This  is  a  valuable 
point  in  differential  diagnosis,  for  chancre,  unlike 
chancroid,  is  usually  multiple  from  the  beginning, 
or  not  at  all,  while  chancroid  may  become  multiple 
by  auto-inoculation.  A  few  apparent  exceptions  to 
this  rule  have  been  noted,  and  Wallace  cites  a  case 
in  which  he  succeeded  in  inoculating  a  man  with 
syphilitic  "virus,"  and  producing  a  true  chancre 
when  the  patient  was  already  in  the  eruptive  stage 
of  the  disease.  Fournier  estimates  that  about  two 
per  cent,  of  auto-inoculations  of  true  chancre  are 
successful,  but  presumably  only  when  some  inflam- 
matory change  in  the  sore  exists.  I  have  already 
expressed  my  belief  that  a  greater  proportion 
might  be  successful  if  performed  sufficiently  early 
in  the  course  of  the  disease.  The  practical  rule, 
however,  is  that  auto-inoculation  of  true  chancre, 
is  not  feasible,  but  may  possibly  succeed  very  early 
in  the  course  of  the  disease.  In  the  stage  of  se- 
queloe  i.  e.,  the  so  called  ''tertiary  period"  the  se- 
cretion of  chancre  in  another  person  may  be  inocu- 
lated, although  rarely. 

The  consideration  of  the  various  secretions,  phy- 
siological and  pathological,  capable  of  transmitting 
syphilis  is  very  important,   and  they  have  been 


Lydston.  43 

quite  exhaustively  studied  by  different  observers 
among  the  most  thorough  of  which  have  been  Bas- 
sereau,  Diday,  Rollet,  Fournier  and  Clerc.  These 
well-known  investigators  have  arrived  at  practically 
the  same  conclusions.  Inoculations  with  the  secre- 
tion of  chancre,  mucous  patches,  any  secondary 
cutaneous  or  mucous  lesion  capable  of  yielding  a 
discharge,  and  of  syphilitic  blood  have  been  made 
with  entire  success.  Whether  the  blood  is  poison- 
ous between  the  periods  of  active  manifestations  of 
the  disease,  has  not  been  determined  by  experiment 
but  from  observations  made  upon  vaccinal  syphilis, 
it  probably  is  inoculable,  and  I  can  see  no  logical 
reason  why  it  should  not  be  so,  inasmuch  as  each 
successive  crop  of  lesions  is  not  due  to  new  devel- 
opment of  the  syphilitic  germinal  cells,  but  to  their 
renewed  activity.  The  secretions  of  lesions  not 
syphilitic,  occurring  upon  a  syphilitic  subject,  are 
not  inoculable  unless  mixed  with  blood,  e.  g. ,  the 
secretions  of  gonorrhoea  and  chancroid  occurring 
in  a  syphilitic  subject,  produce  only  gonorrhoea 
and  chancroid,  unless  there  be  an  admixture  of 
syphilitic  blood.  Diday  inoculated  pus  from  acne 
pustules,  produced  by  the  iodide  of  potassium  on  a 
syphilitic  subject,  but  with  negative  results.  It 
is  also  true  that  vaccine  lymph  derived  from  a 
syphilitic  subject,  is  not  capable  of  producing  syph- 
ilis, unless  it  contains  some  of  the  patient's  blood. 


44  Lectures  on  Syphilis. 

This  should  render  us  none  the  less  cautious,  how- 
ever, for  it  is  very  easy  for  a  small  quantity  of 
blood  to  become  mixed  with  the  lymph,  and 
remain  undetected.  The  vaccine  scab,  from  a 
syphilitic  patient,  is  always  dangerous,  as  it  invari- 
ably contains  a  certain  proportion  of  dried  blood  in 
its  composition.  Inoculations  with  the  secretions  of 
tertiary  lesions  and  with  blood  during  the  tertiary 
stage  of  syphilis  are  negative,  although  there  have 
been  apparent  exceptions  to  this  rule.  Bumstead 
relates  a  case  of  inoculation  of  a  surgeon's  finger 
while  operating  upon  a  case  of  tertiary  necrosis  of 
the  skull,  and  I  may  also  cite  the  case  of  one 
of  my  personal  friends  who  inoculated  his 
finger  while  operating  upon  a  rectal  fistula  in  a 
patient  suffering  from  tertiary  syphilis.  In  due 
time  a  chancre  appeared,  and  was  followed  by  a 
well-marked  development  of  secondary  manifes- 
tions.^ 

The  non-transmissibility  of  syphilis  during  the 
tertiary  period  of  the  disease  is  perhaps  the  strong- 
est evidence  in  favor  of  the  view  that  the  lesions  of 
this  stage  are  not  syphilitic  at  all,  but  are  simply 
sequelae.  Patients  suffering  with  tertiary  mani- 
festations, may  jDrocreate  healthy  children,  but  do 

*The  possibility  of  such  cases  as  those  cited,  being  illustrations 
of  re-infection  of  subjects  suffering  from  "sequelae"  of  a  previous 
attack,  must  be  remembered,  otherwise,  they  would  seem  to  refute 
The  "physiological  pathology." 


Lydston.  45 

not  always  do  so,  and  I  think  that  in  many  cases 
in  which  the  children  are-  fairly  healthy,  and  can- 
not be  pronounced  syphilitic,  there  will  be  some 
slight  manifestations  of  hereditary  taint,  such  as 
imperfect  or  irregular  development  of  the  teeth  or 
those  different  manifestations  of  faulty  nutrition 
which  we  are  wont  to  accept  as  evidences  of  a 
strumous  diathesis.  Hutchinson's  ideas  regarding 
the  elBcacy  of  mercury  and  iodine  in  struma,  have 
probably  a  basis  quite  different  from  the  supposed 
"  anti-strumous "  action  of  these  remedies.  The 
term  "attenuated  syphilis,"  would  be  fitting  for 
many  cases  of  "scrofula."  As  a  rule,  however, 
we  may  accept  the  statement  that  tertiary  syphilis 
is  not  transmissible.  The  later  the  period  of  the 
disease,  the  less  the  liability  to  transmission,  and 
it  is  also  probable  that  the  male  loses  the  power  of 
transmission  before  the  female.  None  of  the 
physiological  secretions,  such  as  mucus,  sweat, 
urine,  milk,  and  semen  are  inoculable,  unless  they 
contain  either  syphilitic  blood,  or  the  secretion  of 
a  syphilitic  lesion.  The  saliva,  so  often  the  me- 
dium of  contagion,  is  innocuous  unless  mucous 
patches  or  other  lesions  exist  in  the  mouth,  in 
which  case,  it  is  contagious  in  the  highest  degree. 
The  syphilitic  cell  (bacillus  ?)  must  be  present,  or  no 
secretion,  physiological  or  pathological,  can  trans- 
mit syphilis. 


Lecture  III. 

Modes  of  conveying  syphilis.— Constitutional  syphilis  always  preceded 
by  chancre,  save  when  foetus  is  infected  hy  the  mother,  or  vice  versa. 
— Explanation  of  the  occasional  apparent  escape  of  mother,  when 
child  is  born  syphilitic. — Escape  of  foetus  when  the  mother  is  infected 
after  the  seventh  month  of  pregnancy.  —Impossibility  of  inoculation 
with  syphilis  when  the  epithelium  is  intact. — Mediate  and  immediate 
m^ethods  of  transmission. — Danger  of  infection  by  kissing. — Danger 
of  infection  of  nurses  by  syphilitic  children,  and  vice  versa. — Colles' 
law. — Example  of  infection  of  a  number  of  persons  by  an  hereditarily 
syphilitic  child.— Transmission  of  syphilis  by  a  healthy  woman.— 
Illustrations  of  mediate  transmission. — Number,  location  and  dura- 
tion of  chancre. —Varieties  of  chancre. — Urethral  chancre.— Compli- 
cations of  chancre.— "Mixed  sores." — Transformation  of  chancre. — 
Treatment  of  chancre. — Syphilitic  bubo. 

Gentlemen: — At  the  conclusion  of  my  last  lec- 
ture, I  had  finished  the  consideration  of  the  various 
secretions  capable  of  transmitting  syphilis,  and  this 
morning  we  will  devote  a  few  moments  to  the  dis- 
cussion of  the  various  modes  of  transmission  of  the 
disease.  As  we  have  seen,  the  presence  of  the 
syphilitic  cell  is  all  that  is  necessary  to  render  any 
secretion,  whether  physiological  or  pathological, 
extremely  contagious,  and  in  the  absence  of  this 
cell  no  contagion  can  occur.  Inasmuch  as  every 
morbid  secretion  due  to  syphilitic  lesions,  contains 
the  syphilitic  ceU;  and  the  lesions  of  syphilis  are 
many  and  various,  occurring  in  any  situation,  we 
can  readily  appreciate  the  fact  that  the  opportuni- 
ties for  transmitting  the  disease,  and  the  methods  of 
its  contraction  are  very  numerous.     The  contag- 


48  Lectures  on  Syphilis. 

iousness  of  the  blood  of  syphilitic  subjects  during 
the  active  period  of  the  disease,  affords  an  additional 
danger,  as  there  are  several  ways  in  which  it  may 
be  accidentally  inoculated.  The  initial  lesion  of 
syphilis  or  chancre,  may  occur  upon  any  portion  of 
the  human  body,  the  only  essential  requisites  for 
its  production  being  a  secretion  containing  the  syphi- 
litic cell,  and  a  surface,  integumentary  or  mucous, 
which  has  been  deprived  of  its  epithelium,  and  is 
consequently  capable  of  absorption  of  extraneous 
matter. 

In  every  method  of  transmission  of  syphilis,  with 
the  exception  of  two,  the  general  disease  is  always 
preceded  by  a  chancre,  and  its  existence  may  be 
inferred,  whether  it  has  been  detected  or  not.     The 
circumstances  in  which  a  chancre  is  never  present 
are,    the   infection  of  the  child  in  utero,  and  the 
infection  of  the  mother  through  the  medium  of  the 
child.     Under   such  circumstances,   the  syphilitic 
cells   enter  the   blood   current   directly,    and   not 
through  the  medium  of  a  localized  process  of  pro- 
liferation, followed  by  a  round-about  tour  of  the 
lymphatics.     Probably  the  same  thing  would  occur 
if  the  syphilitic  virus  were  injected  directly  into  a 
large  blood  vessel.     In  case  the  father  of  the  child 
is  syphilitic,  and  the  mother  healthy,  the  child  may 
escape  infection,  because  the  virus  is  temporarily 
inactive  in  the  father;  either  spontaneously,  or  from 


Lydston.  49 

treatment,  or  the  disease  may  be  so  far  advanced  in 
the  stage  of  sequelse  that  it  ceases  to  be  transmiss- 
ible. Some  authorities  deny  that  the  child  can  be 
infected  by  the  father  directly,  claiming  that  such 
infection  can  only  occur  through  the  medium  of 
the  mother,  but  it  seems  to  me  that  this  view  can 
hardly  be  correct,  for  syphilis  is  surely  quite  as 
capable  of  being  transmitted  in  this  manner,  as  are 
other  morbid  constitutional  conditions.  It  may  at 
least  be  transmitted  as  a  dyscrasia,  if  nothing  more, 
and  I  have  seen  instances  apparently  bearing  out 
both  this  assertion,  and  the  possibility  of  transmis- 
sion of  syphilis  proper.^ »  When  the  mother  is  syph- 
ilitic the  child  is  invariably  infected,  unless  a 
thorough  course  of  treatment  be  instituted  during 
the  period  of  pregnancy,  in  which  case  it  may  pos- 
sibly escape.  Oftentimes,  however,  the  children 
of  syphilitic  women  may  not  develop  the  disease 
until  late  in  life,  thus  leading  to  the  supposition 
that  they  have  escaped  the  disease.  In  such  in- 
stances, the  disease  expends  its  violence  upon  the 
maternal  organism,  and  probably  acts  in  a  manner 
somewhat  analogous  to  vaccinia.  When  the  mother 
is  infected  after  the  seventh  month  of  pregnancy, 
the  child  usually  escapes,  a  point  in  verification  of 

*Otis  however,  claims,  and  with  reason,  that  the  presence  of  the 
syphilitic  cell,  would  inevitably  prove  fatal  to  the  vitality  of  the  sper- 
matozoa, and  that  consequently  the  child  cannot  become  infected, 
save  through  the  maternal  circulation. 


50  Lectukes  on  Syphilis. 

the  views  of  the  pathology  of  syphilis  which  I  have 
in  part  given  you,  and  which  we  will  shortly  dilate 
upon  rather  more  fully. 

The  second  mode  of  contracting  syphilis  without 
the  occurrence  of  a  chancre,  is  the  infection  of  the 
mother  through  the  medium  of  the  child.  This 
too,  is  denied  by  many,  but  I  believe  it  to  occur, 
although  I  am  willing  to  admit  that  the  mother 
often  apparently  escapes  the  disease  entirely  or  has 
very  mild  symptoms.  In  explanation  of  this  fact 
also,  we  have  the  possible  analogy  of  the  foetal  infec- 
tion, to  vaccination,  first  suggested  I  believe  by 
Hutchinson;  syphilis  in  the  mother  being  modified 
greatly,  or  entirely  prevented  by  the  infection  of  the 
child,  in  much  the  same  manner  that  variola  is  mod- 
ified or  prevented  by  vaccination.  The  disease  ex- 
pends its  violence  upon  the  child  in  utero,  thus  ren- 
dering the  subsequent  infection  of  the  mother  com 
paratively  mild,  if  indeed  it  occur  at  all. 

I  have  stated  that  all  that  is  necessary  for  the 
transmission  of  syphilis,  is  the  contact  of  a  secretion 
containing  the  syphilitic  cell  with  an  abraded  sur- 
face. Now,  in  many  instances,  no  abrasion  is 
perceptible,  but  we  infer  that  it  must  necesarily 
have  existed,  inasmuch  as  the  poison  cannot  be  ab- 
sorbed by  the  unbroken  epithelial  surface.  Whether 
the  secretion  containing  the  syphilitic  virus  may 


Lydston.  51 

remain  in  contact  with  a  soiind  surface  of  mucous 
membrane,  until  maceration  and  removal  of  its  epi- 
thelium with  subsequent  absorption  occurs,  is  not 
positively  known,  but  it  is  highly  probable,  and 
may  undoubtedly  occur  in  the  case  of  secretion 
from  a  mixed  sore,  which  is  usually  quite  corrosive 
in  character. 

The  methods  of  contagion  in  syphilis  are  classi- 
fied as  mediate,  and  immediate.  By  the  mediate 
method  we  understand  the  transmission  of  the  dis- 
ease through  the  medium  of  infected  drinking 
utensils,  tobacco  pipes,  towels,  etc.  Chancroid  is 
very  rarely  transmitted  in  this  way,  but  syphilis  is 
quite  often  so  transmitted  on  account  of  the 
multiplicity  of  its  lesions,  w^hich  are  apparently 
so  insignificant  sometimes,  but  none  the  less  infec- 
tious. By  the  immediate  method  of  contagion  we 
mean  the  direct  contact  of  an  abraded  surface  in  a 
healthy  person,  with  a  syphilitic  lesion,  or  syphilitic 
blood  from  a  non-syphilitic  lesion  in  a  syphilitic  sub- 
ject. The  type  of  this  mode  of  contagion,  is  of 
course,  infection  during  sexual  intercourse,  but  it 
may  be  contracted  in  many  other  ways  ;  quite  often 
it  is  contracted  by  the  physician  or  surgeon,  in  opera- 
ting upon  or  examining  syphilitic  subjects.  Some 
of  our  prominent  obstetricians  and  gynecologists 
have  had  sad  experiences  in  this  respect.     Chancre 


52  Lectures  on  Syphilis. 

is  sometimes  contracted  in  kissing,  a  little  mucous 
patch  upon  the  lips  or  tongue  of  the  diseased  per- 
son inoculating  any  slight  fissure  or  abrasion  upon 
the  lips  of  the  healthy  subject.  I  have  known  of 
very  sad  examples  of  this  method  of  contagion. 
A  short  time  since,  I  treated  a  young  married  man 
for  chancre  of  the  tongue  contracted  in  this  man- 
ner, and  I  have  seen  several  probably  innocent 
women  with  labial  chancre.  Infants  may  contract 
syphilitic  chancre  from  the  nipples  of  syphilitic 
nurses,  and  on  the  other  hand,  a  healthy  nurse  may 
contract  chancre  of  the  nipple,  from  a  syphilitic 
infant.  Colles'  law,  so-called,  that  a  hereditarily 
syphilitic  infant,  cannot  infect  its  mother,  depends 
simply  upon  the  fact  that  in  many  cases  the  mother 
already  has,  or  has  had  syphilis,  or  as  already  sug- 
gested, the  possible  analogy  to  vaccinia  may  explain 
it,  the  syphilization  of  the  infant  having  afforded  im- 
munity for  the  mother.  For  my  own  part,  I  have 
strong  doubts  as  to  the  potency  of  this  so-  called 
law  of  Abram  CoUes,  and  hold  to  the  opinion  that 
a  syphilitic  infant  should  never  be  nursed  by  an 
apparently  healthy  mother.  My  views  upon  this 
subject  will  be  presented  hereafter. 

As  an  illustration  of  the  danger  of  immediate 
contagion,  in  case  one  member  of  a  family  should 
contract  syphilis,  I  will  mention  an  instance  which 


Lydston.  53 

I  reported  in  the  N.  Y.  Medical  Record  a  few 
months  ago :  A  young  married  man  contracted 
syphilis,  and  communicated  it  to  his  wife,  who  was 
then  in  the  seventh  month  of  pregnancy.  The 
child  was  born  apparently  healthy,  and  remained 
so  up  to  the  age  of  three  years,  when  it  died  of 
some  acute  disease  of  the  lungs,  not  supposed  to  be 
of  a  syphilitic  character.  A  second  child  was 
born  sixteen  months  later,  which  was  unequivo- 
cally syphilitic.  From  this  child,  its  grandmother 
and  one  aunt,  contracted  chancre  of  the  mouth,  and 
the  grandmother  subsequently  infected  the  grand- 
father, after  which  the  disease  was  diagnosed  by 
the  family  physician.  Thus  from  the  indiscretion 
of  one  member  of  the  family,  five  innocent  persons 
were  infected  with  syphilis.  Tlie  fact  that  the 
first  child  apparently  escaped,  is  important  as  bear- 
ing out  the  assertion  of  Diday,  that  in  case  the 
mother  is  infected  after  the  seventh  month  of 
utero-gestation,  the  foetus  escapes  the  disease. 

There  are  many  interesting  examples  of  the 
mediate  method  of  contracting  syphilis.  Instances 
have  been  known  in  which  a  man  with  a  long  pre- 
puce, has  had  intercourse  with  a  syphilitic  female, 
and  shortly  afterward  with  his  wife,  infecting  the 
latter,  while  he  himself  escaped  the  disease,  the 
virus,  having  been  retained  beneath  the  prepuce  and 


54  Lectures  on  Syphilis. 

subsequently  deposited  in  the  healthy  vagina. 
Again,  the  syphilitic  poison  may  be  deposited  in 
the  vagina  of  a  female,  by  her  lover,  and  her  hus- 
band, embracing  her  shortly  afterward,  receives  the 
souvenir  the  lover  left  him,  while  the  vroman  herself 
escapes.  These  facts  must  be  borne  in  mind,  for 
they  may  be  of  service  to  you  hereafter.  Tobacco 
pipes,  drinking  utensils,  and  the  tubes  used  by 
glass-blowers,  are  familiar  media  of  syphilitic  con- 
tagion. There  is  an  instance  related,  in  which  a 
whole  glass-blowing  establishment  became  infected 
by  the  blow  pipe,  as  it  was  passed  from  mouth  to 
mouth.  In  this  case,  one  of  the  workmen  had  a 
few  small  mucous  patches  in  his  mouth,  and  from 
this  man,  the  whole  party  contracted  syphilis. 
Vaccination  is  also  a  familiar  mode  of  contagion, 
less  frequently  however,  than  is  generally  sup- 
posed, for  if  the  meanness  ol  generations  past, 
should  happen  to  manifest  itself  at  the  time  of  the 
vaccination,  particularly  if  humanized  virus  is 
used,  the  trouble  is  invariably  laid  at  the  door 
of  the  doctor.  An  interesting  instance  of  the 
wide  dissemination  of  syphilis  by  mediate  trans- 
mission is  that  in  which  an  entire  community  was 
infected  by  an  itinerant  tattoo  artist,  who  used  his 
own  saliva  in  mixing  his  inks.  The  usual  explana- 
tion of  mucous  patches  in  the  mouth,  holds  true  in 
this  case. 


Lydston.  55 

The  duration  of  syphilitic  chancre  is  variable. 
It  may  last  for  a  couple  of  weeks,  and  in  the  major- 
ity of  cases,  an  eruption  appears  prior  to  the  disap- 
pearance of  the  chancre.  Chancre  is  generally 
single,  but  may  be  multiple,  according  to  the  num- 
ber of  points  primarily  inoculated.  It  is  usually 
situated  upon  the  genitals,  and  particularly  behind 
the  corona  glandis  in  the  male,  but  its  situation 
may  vary  greatly,  as  may  be  readily  seen  upon 
considering  its  numerous  methods  of  contagion. 
Chancres  of  the  face,  tongue  and  nipple  are  not  so 
very  rare,  and  instances  of  chancre  of  the  tonsil 
have  been  reported.  Urethral  chancre  is  not  un- 
commonly seen. 

I  have  already  described  to  you,  the  various 
forms  of  induration  of  chancre,  but  a  further  des- 
cription of  the  sore,  particularly  of  the  ulceration, 
may  be  of  service.  A  chancre  may  consist  of  (1) 
An  erosion,  (2)  An  ulceration,  (3)  A  deep  funnel- 
shaped  ulceration  or  (4)  of  a  dry  indurated  papule.* 
(1)  Erosion  is  said  to  include  about  two-thirds  of 
chancres,  and  is  usually  situated  upon  mucous  mem- 
brane, very  often  inside  the  prepuce.  In  shape  it 
is  oval  or  perhaps  a  trifle  irregular,  with  a  raw, 
polished  surface  of  a  wine  red  color,  and  sometimes 
a  pultaceous  base,  but  usually  secreting  a  simple 

*  Vide  Vanburen   and    Keyes,    "  Genito-Urinary    Diseases     with 
Syphilis." 


56  Lectures  on  Syphilis. 

thin,  sanious  fluid,  devoid  ol  pus,  or  at  least  con- 
taining a  very  small  amount  of  pus  corpucles. 
These  erosions  are  flat  and  may  surmount  a  thin 
parchment  induration,  or  may  cap  a  hard  lump  as 
large  as  a  marble.  (2)  Superficial  ulceration  with 
sloping  edges  is  found  with  the  parchment,  or  most 
often  with  the  split  pea  induration.  (3)  When  this 
ulceration  caps  a  large  mass  of  induration,  it  is 
likely  to  be  quite  deep  and  funnel-shaped,  consti- 
tuting the  so  called  "Hunterian  chancre."  The 
secretion  from  a  chancrous  ulceration,  is  quite 
likely  to  be  of  a  sero-purulent  character.  (4)  The 
indurated  papule,  is  usually  seen  upon  the  skin,  or 
upon  the  integument  of  the  penis,  or  even  upon 
the  prepuce  when  it  is  short  and  dry.  Ulceration 
of  this  form  of  induration  might  occur,  if  it  were 
kept  moist,  the  conditions  of  warmth,  moisture 
and  irritation  combined,  being  especially  favorable 
to  the  production  of  ulceration.  I  think  that  the 
parts  upon  which  it  develops,  are  not  so  rich  in 
lymphatic  spaces  as  those  tissues  in  which  a  chan- 
cre is  more  likely  to  ulcerate,  the  collection  of  cells 
being  consequently  smaller,  and  the  tendency  to 
necrobiosis  less  marked. 

The  symptoms  ot  urethral  chancre  when  too 
deep  to  be  seen,  consist  in  a  discharge  coming  on 
after  the  usual  period  of  incubation,  this  discharge 


Lydston,  57 

being  thin,  and  perhaps  sanious,  but  sometimes 
creamy  and  thick,  and  a  painful  spot  in  the  urethra, 
which  is  especially  noticeable  during  micturition 
and  erection,  with  possibly  a  lump  in  the  course  of 
the  canal,  which  is  plainly  perceptible  on  palpation 
with  the  thumb  and  finger,  in  some  cases.  By 
means  of  the  endoscope,  an  ulcer  may  be  detected, 
and  in  a  short  time  the  general  enlargement  of  the 
glands  and  other  symptoms,  clear  up  the  diagnosis. 
There  are  some  complications  of  syphilitic  chan- 
cre that  are  worthy  of  attention :  1st.  First  and 
simplest  we  have  vegetations  or  warty  growths — 
the  so-called  venereal  warts,  which  result  from 
local  irritation,  in  combination  with  heat  and  moist- 
ure, and  are  identical  with  those  occurring  under 
other  circumstances.  Proper  measures  of  cleanli- 
ness will  prevent  their  formation,  but  if  they 
appear  in  uncleanly  persons,  caustics  or  the  scissors 
are  necessary  for  their  removal.  2d.  Inflamma- 
tion of  chancre  sometimes  occurs,  giving  rise  to 
considerable  pain  and  profuse  purulent  secretion. 
3d.  Chancre  may  be  complicated  by  chancroid, 
constituting  a  "mixed  sore,"  unless  the  two  forms 
of  disease  appear  in  difierent  localities.  When  a 
chancre  becomes  inoculated  with  chancroid,  its 
ulceration  deepens,  and  it  gradually  assumes  the 
general  characters  of  chancroid,  but  unless  phag- 


58  Lectures  on  Syphilis. 

edaena  occurs,  induration  still  persists.  When 
chancroid  develops  primarily,  it  runs  its  usual 
course,  until  the  incubation  period  of  syphilis  has 
elapsed,  when  induration  occurs.  The  secretion  of 
the  "mixed  sore, "is  auto-inoculable,  and  is  capable 
of  transmitting  either  disease  alone,  or  both 
together,  to  a  healthy  person.  In  some  cases  chan- 
croid appears  and  rapidly  heals,  or  the  incubation 
period  of  syphilis  is  long,  and  we  have  induration 
developing  in  the  cicatrix  of  the  chancroid,  after  it 
has  perfectly  healed.  The  test  for  mixed  chancre 
is  auto-inoculation  :  Any  indurated  sore^  the  secre- 
tion of  ^vhic/i  is  auto-inoculable,  in  the  true  sense 
of  the  word,  and  which  is  follotved  hy  constitu- 
tional syphilis^  is  a  ''^  mixed  chancre.''''  When  we 
\ise  the  term  ''^auto-inoculable^''  we  mean  a  sore,  the 
secretion  of  which^  inoculated  in  a  new  situation  in 
the  diseased  individual,  will  produce  chancroid. 
The  methods  of  contraction  of  mixed  chancre  are 
two,  viz  :  Both  poisons  may  be  contracted  simul- 
taneously, or  either  form  of  sore  may  develop  pri- 
marily, and  subsequently  become  inoculated  with 
the  other  form  of  disease. 

Typical  syphilitic  chancre,  may  undergo  marked 
transformations,  e.  g.  a  chancrous  induration,  par- 
ticularly when  situated  in  a  moist  locality,  may  lose 
its  hardness,  and  at  the  same  time  become  trans- 


Lydston.  59 

formed  into  a  mucous  patch,  by  becoming  covered 
with  a  characteristic  whitish  pellicle.  In  some 
instances  the  sore  acquires  the  form  of  the  mucous 
patch,  and  nevertheless  retains  its  characteristic 
induration.  Phagedsena  may  attack  a  true  chancre, 
and  when  it  does  so,  is  quite  likely  to  be  of  the 
gangrenous  form.  The  pultaceous  and  serpiginous 
varieties,  are  quite  rarely  seen  under  such  circum- 
stances. After  phagedtena  has  once  invaded  a 
chancre,  induration  is  no  longer  perceptible.  If 
the  sore  be  of  the  mixed  variety,  we  are  then  quite 
likely  to  have  the  pultaceous  or  serpiginous  form 
of  phagedi\?na.  Such  authorities  as  Bassereau  and 
Diday  think  that  the  type  of  syphilis  following 
phagedeenic  chancre  is  apt  to  be  exceptionally 
severe.  This  is  explicable  by  considering  the  fact 
that  phagedena  is  due  to  general  debility,  or  a 
peculiar  diathesis,  which  lessens  the  resisting 
power  to  any  disease,  and  especially  to  syphilis, 
rather  than  by  any  extraordinary  intensity  of 
the  syphilitic  infection. 

The  treatment  of  syphilitic  chancre  is  very  sim- 
ple, when  no  complications  exist.  The  yellow  or 
black  wash  may  be  applied,  and  constitute  the 
best  applications  that  can  be  used.  According  to 
the  new  pharmacopoea,  the  lotio  flava  or  yellow 
wash,  consists  of  1 8  grains  of  the  bichloride  of  mer- 


60  Lectures  ox  Syphilis. 

cury  to  10  ounces  of  liq.  calcis,  and  the  lotio  nigra 
or  black  wash,  of  30  grains  of  calomel  to  10  ounces 
of  liq.  calcis.  These  preparations  should  be  well 
shaken  before  being  used,  or  very  little  of  the  salt 
of  mercury,  which  exists  in  the  form  of  a  precipi- 
tate, will  be  applied.  The  mild  chloride  of  mercury 
with  zinc  oxide,  forms  a  very  efficient  dressing. 
Cauterization  of  simple  hard  chancre  should  never 
be  practiced,  as  it  will  simply  cause  painful  inflam- 
mation in  an  otherwise  insignificant  lesion.  If, 
however,  the  sore  is  of  the  mixed  variety,  its  chan- 
croidal property  should  be  destroyed  by  cauteriza- 
tion, after  which  iodoform  in  powder  should  be 
applied.  All  sources  of  irritation  should  be  care- 
fully avoided,  and  perfect  cleanliness  insisted  upon. 
AYhen  phagedtena  occurs,  mercury  is  essential  to 
counteract  the  debilitating  influence  of  the  consti- 
tutional poison,  and  for  my  own  part  I  believe  that 
the  internal  administration  of  mercury  should  be 
begun,  as  soon  as  the  diagnosis  of  syphilitic  chan- 
cre is  perfectly  clear,  and  by  following  this  course, 
I  very  seldom  see  any  manifestations  of  the  disease 
other  than  a  slight  roseola,  with  perha]3S  a  few 
trifling  mucous  patches,  during  the  entire  course  of 
treatment.  It  is  very  essential  to  prevent  eruptions, 
upon  the  face  especially.  Whenever,  on  the  other 
hand,  there  is  the  slightest  doubt  as  to  the  correct- 


Lydston.  61 

ness  of  the  diagnosis,  no  mercury  should  be  given, 
until  the  question  is  decided  by  the  appearance  of 
symptoms  unequivocally  syphilitic. 

We  have  already  noted  the  o-landular  enlarge- 
ments that  succeed  the  appearance  of  the  syphilitic 
chancre.  These  are  sometimes  termed  "syphilitic 
bubo. "  It  may  occur  in  any  situation  where  there 
are  lymphatic  glands  in  the  vicinity  of  a  chan- 
cre, being  naturally  most  often  found  in  the  groin. 
The  groups  of  glands  involved,  vary  according  to 
the  location  of  the  chancre.  In  chancre  of  the 
penis,  uretha,  groin,  buttocks^  anus,  lower  part  of 
the  abdomen,  scrotum,  thighs,  or  rectum,  the 
inguinal  or  femoral  glands,  or  both,  are  involved. 
In  chancre  of  the  lips  and  mouth,  the  submaxillary 
lymphatics,  and  in  chancre  of  the  face,  the  pre-au- 
ral  gland  are. involved.  When  the  finger  is  inocu- 
lated, we  have  enlargement  of  the  glands  in  the 
axilla.  General  glandular  enlargement  eventually 
occurs,  but  the  changes  are  first  evident  in  the  con- 
tiguous glands,  and  they  are  always  more  mark- 
edly enlarged  than  any  of  the  others.  When  the 
inguinal  glands  are  implicated,  they  are  grouped  in 
a  peculiar  fashion.  This  group,  termed  by  Ricord, 
the  "pleiad, "  consists  usually  of  one  large  gland, 
surrounded  by  from  two  or  three,  to  six  or  eight  of 
smaller   size.     The   enlargement  is  generally  not 


62  Lectures  on  Syphilis. 

very  great,  but  is  peculiar  in  some  respects.  There 
is  little  or  no  pain  or  tenderness,  and  the  glands 
are  freely  movable  under  the  skin,  being  distinctly 
outlined  and  not  matted  together.  As  a  rule  they 
have  the  hard,  woody  feel  of  the  chancre,  but 
exceptionally  they  are  softer  and  more  elastic. 
Enlargement  of  the  glands  begins  usually  about 
the  second  week  after  the  appearance  of  the  chan- 
cre, and  Fournier  remarks  a  case  in  which  enlarge- 
ment did  not  occur  until  the  twenty -seventh  day,  as 
unique.  Instead  of  the  peculiar  group  known  as 
the  pleiad,  Ave  may  have  a  single  moderately 
enlarged  gland,  or  perhaps  an  enormously  swollen 
gland  as  large  as  a  hen's  egg^  on  one  or  both  sides. 
Such  enlargements  have  been  carefully  studied  by 
Bassereau,  and  found  to  consist  of  small  glands, 
matted  together  with  enlarged  lymphatic  vessels 
and  firm  connective  tissue. 

The  important  practical  point,  to  which  I  desire 
to  call  your  attention  in  connection  with  syphilitic 
bubo,  is  that  each  indurated  gland  is  but  a  repeti- 
tion of  the  neoplastic  formations  of  which  the 
chancre  is  the  prototype.  It  is  hard,  and  woody, 
comparatively  painless,  perfectly  circumscribed, 
and  not  prone  to  suppuration,  and  all  because  of 
those  same  characteristic  microscopical  features, 
which  we  have  studied  in  the  chancre.     Under  the 


Lydston.  63 

microscope,  we  have  the  same  collection  of  cells  of 
several  forms,  the  large,  round,  multi-micleatecl 
granular  cell  being  in  the  preponderance,  and  the 
same  proliferation  of  the  surrounding  connective 
tissue,  that  we  see  in  a  section  of  a  hard  chancre. 
Syphilitic  bubo  attains  its  full  development  in 
from  one  to  three  weeks,  and  may  then  remain 
stationary  for  some  weeks  or  months,  or  perhaps 
it  may  last  for  over  a  year.  It  is  usually  present, 
and  may  suddenly  increase  in  size  when  the  early 
eruptions  appear,  but  in  exceptional  instances,  it 
may  speedily  disappear  from  unknown  causes. 
Suppuration  rarely  attacks  syphilitic  bubo,  and 
when  it  does  occur,  it  is  the  result  of  inflammatory 
irritation  or  of  a  strumous  diathesis,  and  its  pus  is 
not  auto-inoculable.  When  pus  from,  a  hubo  is 
auto-inoculable^  the  jprirriaTy  sore  naist  necessarily 
have  heen  either  a  'mixed  sore,  or  pure  chancroid. 
Induration  of  the  lymphatics  is  so  rarely  absent  in 
syphilitic  chancre  that  practically  it  may  be  said 
to  always  exist.  It  is  likely  to  be  absent  in  cases 
of  second  infection,  and  according  to  Ricord,  is  not 
present  in  phagedeenic  chancre.  I  have  myself 
seen  several  cases  of  phageda?nic  sloughing  in  hard 
chancre,  in  which  bubo  did  not  appear,  although 
general  adenopathy  developed  in  connection  with 
the  general  symptoms.     I  can  oflfer  no  explanation 


64  Lectures  on  Syphilis. 

for  this,  and  must  confess  that  it  does  not  enhance 
the  sti'ength  of  the  position  which  I  have  assumed 
as  to  the  pathology  of  the  disease,  and  in  which  I 
have  adopted  the  views  of  Otis.  Such  cases  would 
naturally  bring  up  a  question  to  which  I  have 
already  alluded,  viz  :  Whether  there  may  not  be 
two  elements  in  syphilization,  one  local,  and  the 
other  constitutional.  In  cases  in  which  there  is 
considerable  subcutaneous  fat,  bubo  may  not  be 
perceptible.  As  a  rule  syphilitic  buboes  gi^adually 
attain  their  maximum  development,  and  as  gi'ad- 
ually  disappear,  either  spontaneously,  or  as  the 
effect  of  administration  of  mercury,  in  the  same 
manner  as  the  chancre  itself  eventually  resolves. 
Although  as  I  haA^e  stated,  they  rarely  suppurate, 
these  glandular  enlargements  are  prone  to  caseous 
degeneration,  when  the  subject  is  of  a  strumous 
diathesis.  Virulent  suppuration  may,  of  course, 
ensue  in  cases  of  mixed  sore,  or  if  the  sore  how- 
ever innocent  in  ap^Dearance  at  its  commencement, 
should  subsequently  become  irritated  and  inflamed. 
In  the  former  case,  the  pus  is  auto-inoculable,  but 
in  the  latter  it  is  not. 

The  treatment  of  syphilitic  bubo  is  that  of  gen- 
eral syphilis,  unless  suppuration  occurs,  in  which 
case  it  must  be  treated  upon  ordinary  surgical 
principles.     As  I  shall  be  unable  to  give  you  a 


Lydston,  65 

special  lecture  upon  the  treatment  of  bubo,  I 
should  be  pleased  to  have  you  refer  to  an  article  in 
the  Chicago  Journal  and  Examiner^  in  which  I 
have  presented  my  views  upon  the  subject.^  We 
leave  the  subject  of  syphilis  at  this  point  this  morn- 
ing, gentlemen,  and  in  my  next  lecture  I  will 
endeavor  to  give  you  an  idea  of  the  patholoofy  of 
''general  syphilitic  infection." 

*  Vide  Chicago  Journal  and  Examiner,  May,  1883. 


Lecture  IV. 

General  infection. — Importance  of  a  knowledge  of  the  site  of  the  pri- 
mary lesion. — Universal  susceptibility  of  the  tissues  to  the  syphilitic 
process. — Termination  of  the  initiatory  period  and  commencement  of 
general  infection. — Progression  of  the  syphilitic  cells. — The  periods 
of  quiescence  not  true  periods  of  incubation.— Explanation  of  the 
apparent  periods  of  incubation.— First  manifestation  of  constitu- 
tional disease. — The  roseola. —Occasional  coincidence  of  febrile  and 
other  symptoms  with  the  roseola.— The  roseola  not  due  to  prolifer- 
ation of  cells. — The  so-called  "syphilitic  fever." — Explanation  of 
syphilitic  sore  throat.— The  syphilitic  papule.— Structure  of  papule 
and  explanation  of  its  occurrence.— Syphilitic  alopecia  and  onychia.— 
Cause  of  ulceration  and  suppuration  of  papule. — Mucous  patches, 
tubercles,  and  condylomata. — Causes  and  structure  of  the  "plaques 
muqueuse."— Syphilitic  iritis. — Osseous  lesions  of  active  period. — 
Duration  of  the  active  period  of  syphilis. 

Gentlemen  : — We  now  come  to  the  interesting 
topic  of  "general  syphilis"  or  the  "period  of  gen- 
eral infection  and  subsequent  localized  cell  accu- 
mulation"." The  period  covering  the  develop- 
ment of  the  chancre  with  its  attendant  and  consec- 
utive lymphitis  and  adenitis,  which  we  have  termed 
the  initiatory  period,  or  if  we  may  use  the  expres- 
sion "local  syphilis,"  is  also  and  more  frequently 
known  as  "primary  syphilis."  Inherited  syphilis 
has  no  primary  period,  being  general  from  its  very 
commencement,  but  acquired  syphilis  has  ahvays  a 
primary  stage.  This  is  of  great  practical  impor- 
tance, for  wherever  we  meet  secondary  syphilis,  we 
can  positively  affirm  that  there  must  necessarily 
have  heen  a  chancre  somewhere^  and  this  must  have 

*"Vide  Otis. 


68  Lectures  on  Syphilis. 

heen  attended  hy  adenitis,  however  obscure  or 
slight  the  symptoms  may  have  heen.  Now  it  is 
sometimes  very  important  to  decide  where  these 
local  changes  were  manifest.  Only  a  few  months 
ago,  I  was  consulted  in  regard  to  a  young  lady 
suffering  with  active  secondary  syphilis,  the  origin 
of  which  she  professed  to  be  entirely  ignorant  of. 
Her  relatives  seemingly  had  no  suspicion  as  to  the 
possible  source  of  her  trouble,  and  she  was  brought 
to  me  by  the  gentleman  to  whom  she  was  engaged 
to  be  married.  This  gentleman  had  his  own  sus- 
picions, but  generously  gave  the  woman  the  benefit 
of  a  doubt  existing  in  his  own  mind,  as  to  the  pos- 
sibility of  her  having  contracted  some  simple  dis- 
ease b}^  kissing,  he  himself  having  a  sore  mouth  at 
the  time.  A  careful  investigation  revealed  the  fact 
that  she  had  never  had  the  slightest  trouble  with 
her  mouth  or  throat,  until  the  late  secondary 
pharyngeal  manifestations  for  which  she  consulted 
me,  appeared,  and  in  addition,  she  innocently 
stated  that  she  had  had  about  a  year  previous  to 
her  consulting  me,  some  little  ' '  tender  lumps  "  in 
the  groins.  There  had  never  been  any  ' '  kernels  " 
as  she  termed  them  in  the  neck  beneath  the  jaws. 
These  points  settled  the  question  as  to  the  localit}^ 
primarily  affected,  and  a  candid  statement  of  the 
case  saved  the  young  man  a  mesalliance.      The 


Lydston.  69 

woman  is  probably  congratulating  herself  upon 
her  success  in  duping  me,  but  wondering  at  the 
disappearance  of  her  affianced,  he  having  with- 
drawn in  the  easiest  manner  possible  by  leaving 
the  city. 

The  initiatory  period  of  syphilis  terminates,  when 
the  diseased  cells  have  traversed  the  lymphatics 
leading  from  the  chancrous  surface,  have  entered 
the  receptaculum  chyli  and  from  thence  passed 
into  the  blood,  through  the  medium  of  which  they 
are  disseminated  throughout  the  system,  giving 
rise  to  the  peculiar  changes  characteristic  of  syph- 
ilis, in  every  tissue  and  organ  in  the  body ;  the 
changes  being  more  marked  in  some  organs  per- 
haps than  in  others,  in  different  cases,  but  there 
being  no  tissue  of  the  body  which  enjoys  complete 
immunity  from  the  ravages  of  the  disease.  The 
various  bodily  functions  may  be  impaired,  the 
special  senses  and  sexual  appetite  destroyed,  par- 
alyses may  occur,  and  even  the  intellect  itself  may 
be  ruined  by  this  terrible  malady. 

I  will  now  direct  your  attention  to  the  pathology 
of  the  various  manifestations  of  the  period  of 
"general  syphilitic  infection."  We  have  seen  that 
the  period  of  local  manifestations  of  syphilis  is 
preceded  by  a  period  of  incubation,  lasting  on  an 
average  twenty-one  days.     Following  the  initiatory 


70  Lectdkes  on  Syphilis. 

period  we  have  another  apparent  period  of  incuba- 
tion, lasting  on  an  averas^e  forty  to  forty-five  days, 
and  foUowed  by  general  syphilis.  Now,  gentle- 
men, it  would  appear  that  these  periods  of  quies- 
cence are  not  true  periods  of  incubation,  but  are 
periods  during  which  there  is  "an  interference  with 
the  progress  of  the  diseased  cells  by  normal  anatom- 
ical and  physiological  barriers."  During  the 
second  stage  of  incubation  so-called,  (this  stage 
we  will  shortly  subdivide  into  several  apparent 
incubative  periods)  Avhich  as  we  have  seen,  lasts 
on  an  average  forty  to  forty-five  days,  the 
syphilitic  germinal  cells  are  slowly  traversing  the 
lymphatics,  and  graduallj^  making  their  way  to 
the  general  blood  current.^  They  are  not  ferment- 
ing^ and  thus  preparing  for  an  explosion^  hut  are 
slowly  traveling  on  through  the  lymphatic  system^ 
proliferating  and  multiplying  hy  the  way^  and  not 
only  changing  themselves^  hut  exciting  propensities 
for  evil  in  the  lymphatic  and  connective  tissue 
elements  with  vjhich  they  come  in  contact^  and  to 
which  they  impart  their  own  infectious  and  other 
mjorhid  properties^  particularly  their  inorhid 
activity  and  ahnormal  tendency  to  proliferation. 

Grenerally  we  have  only  the  chain  of  glands 
intervening  between  the  local  induration,  and  the 
lymphatic  reservoir  or  receptaculum  chyli,  indura- 

*  Otis  insists  upon  this  point  with  especial  emphasis. 


Lydston.  71 

ted  until  just  before,  or  at  the  time  of  the  manifes- 
tations of  general  syphilis,  sometimes,  however, 
the  general  lymphatic  system  is  involved  prior  to 
the  appearance  of  the  eruption,  and  there  is  an 
undoubted  increase  in  size,  coincident  with  the 
eruption.  Now  why  is  it  that  we  have  an  interval 
between  the  appearance  of  the  local  induration, 
and  the  enlargement  of  the  nearest  lymphatic 
glands,  another  between  this  glandular  enlarge- 
ment and  general  glandular  hyperplasia,  and  still 
another  sometimes,  between  the  general  glandular 
enlargement  and  the  appearance  of  the  first  erup- 
tion 'i  I  think  that  very  good  reasons  can  be 
given  for  their  occurrence :  In  the  first  place, 
a  certain  length  of  time  must  elapse  before  the 
diseased  cells  can  leave  the  original  focus  of  infec- 
tion, viz.  the  chancre,  traverse  the  intervening 
lymphatic  vessels,  and  arrive  in  the  nearest  lym- 
phatic glands ;  here  the  cells  produce  that  charac- 
teristic effects  as  evidenced  by  the  development  of 
syphilitic  bubo,  and  while  the  glands  become  en- 
larged, the  cells  which  have  excited  the  morbid 
changes,  with  others  which  have  joined  them  and 
become  infected  by  the  way,  travel  slowly  on 
toward  the  receptaculum  chyli,  and  thence  to  the 
general  system  by  way  of  general  circulation. 
This   requires   a  certain  interval  of  time,  for  no 


72  Lectures  on  Syphilis. 

morbid  manifestations  can  occur  until  the  cells 
have  reached  their  destination.  Thus  we  have  an 
explanation  of  the  second  apparent  period  of  incu- 
bation which  has  been  named. 

As  we  have  seen,  the  syphilitic  germinal  cells 
eventually  arrive  at  the  receptaculum  chyli,  from 
which  they  are  carried  to  the  general  circulation, 
and  after  entering  the  right  heart,  are  finally  dis- 
seminated throughout  the  tissues  generally,  pro- 
ducing their  characteristic  effects,  a  first  evidence 
of  which  may  consist  in  a  general  glandular  en- 
largement sometimes  seen  prior  to  the  eruption. 
In  cases  in  which  the  glands  react  prior  to  the 
appearance  of  an  eruption; — the  possibility  of  this 
is  denied  by  some,  good  authorities  claiming  that 
glandular  enlargement  is  always  coincident  with,  or 
consecutive  to  the  eruption;  my  own  experience  is 
that  they  often  become  enlarged  prior  to  the  erup- 
tion.— there  is  a  consequent  interval  between  gen- 
eral adenitis  and  the  syphilitic  eruption.  This  is 
due  to  the  fact  that,  although  the  diseased  cells  ar- 
rive in  other  tissues  of  the  body  through  the  medi- 
um of  the  blood,  quite  as  soon  as  in  the  lymphatics, 
the  latter  are  likely  to  be  the  first  tissues  to  respond 
to  the  morbid  influence  exerted  by  the  cells.  To 
be  sure  the  glands  usually  respond  rather  tardily, 
and  are  not  perceptibly  enlarged  until  the  eruption 


Lydston.  73 

appears,  but  in  my  estimation  many  cases  are  ex- 
ceptions to  this  rale.  If  the  lymphatic  glands  are 
already  enlarged  when  the  eruption  appears,  they 
immediately  still  further  increase  in  size,  the  pro- 
liferation of  cells  being  excited  to  renewed  activity 
at  this  time.  We  have  thus,  it  seems,  explained  the 
reasons  for  the  three  apparent  periods  of  incuba- 
tion, and  have  endeavored  to  demonstrate  the  fact 
that  they  are  not  true  periods  of  incubation  or 
quiescence  at  all,  but  are  periods  during  which  the 
cells  are  still  slowly  marching  on,  and  which  are 
necessary,  in  order  that  the  cells  may  reach  the 
tissues  which  are  successively  involved. 

The  first  period  of  incubation  occurring  in  the 
natural  course  of  syphilis,  I  have  not  yet  touched 
upon,  but  we  will  now  analyze  it,  and  see  if  we 
cannot  explain  it  in  a  manner  somewhat  similar  to 
that  involved  in  the  explanations  just  given  for  the 
other  periods  of  quiescence.  This  first  period  of 
incubation,  is  the  most  important  of  all  the  so- 
called  incubative  periods,  and  as  1  shall  endeavor 
to  show  you,  is  like  the  others,  in  that  it  is  apparent 
and  not  real.  Now  the  question  may  arise,  in  the 
minds  of  even  those  among  you  who  are  perfectly 
willing  to  accept  the  statements  as  to  the  other 
stages  of  quiescence  being  apparent  and  not  real, 
as  to  whether  this  first  period,  which  intervenes  be- 


74  Lectures  on  Syphilis, 

tween  the  occurrence  of  inoculation  with  intectious 
material,  and  the  appearance  of  the  initial  indura- 
tion, is  not  a  stage  of  true  incubation.  Such  a 
question  would  be  but  natural,  for  it  would  certain- 
ly appear  from  the  long  stage  of  quiescence,  that 
the  virus  of  syphilis  was  undergoing  a  sort  of 
development  or  fermentive  change,  at  the  cul- 
mination of  which  an  explosion  naturally  followed, 
in  the  form  of  a  chancre.  Now  it  is  my  own  be- 
lief, as  formed  from  a  careful  survey  of  the  inves- 
tigations and  teachings  of  Besiadecki,  Baiimler, 
Otis  and  others,  that  local  changes  hegin  as  soon  as 
the  syphilitic  virus  has  been  ahsorhed.  These 
changes  are  very  gradual,  it  is  true,  and  probably 
consist  at  first,  of  the  incorporation  of  the  syphilitic 
germinal  cell"^  (which  as  we  have  seen  is  a  degraded 
cell,  and  may  be  of  a  diameter  of  only  1-100,000  of 
an  inch),  with  the  lymphatic  elements  of  the  infected 
tissues.  A  certain  length  of  time  is  necessary,  be- 
fore the  degraded  syphilitic  cells  reach  the  lymph 
spaces,  and  again,  some  little  time  is  necessary  for 
their  incorporation  with  the  lymph  cells. 

We  now  have  a  slow  proliferation  of  the  lym- 
phatic elements,  which  are  now  syphilitic  germinal 
cells,  and  possessed  of  new  properties  which  are 
morbid,  as  well  as  an  intensification  of  their  physi- 
ological properties.     The   chief  new   and  morbid 

*0r  bacillus  of  Lustgarten,  if  proven. 


Lydston.  75 

property  which  they  have  acquired,  is  that  of  infec- 
tiousness, and  those  normal  properties  already 
existing  but  which  now  become  intensified,  are 
those  of  amoeboid  activity,  and  power  of  prolifera- 
tion. The  multiplication  of  cells  becomes  more 
active,  the  connective  tissue  elements  of  the  blood- 
vessels and  lymphatic  walls  become  involved,  pro- 
ducing as  we  have  already  seen,  partial  occlusion 
of  thuir  lumen,  and  a  consequent  "anaemia  of 
tissue."  The  smaller  lymphatic  vessels  are  now 
reached,  and  the  accumulation  of  cells  is  so  exten- 
sive that  a  preceptible  induration  is  noticed.  This 
area  of  induration  increases  in  size  until  the  cell 
accumulation  of  which  it  is  composed,  has  free 
communication  with  the  larger  lymphatics,  and  the 
smaller  lymphatics  regain  their  permeability. 
From  this  time  on,  the  cells  are  removed  by  the 
lymphatics  as  fast  as  they  are  formed.  Finally, 
local  proliferation  having  entirely  ceased,  the  cells 
composing  the  induration  are  entirely  removed  by 
the  absorbents,  or  undergo  fatty  degeneration  and 
resolution  from  the  administration  of  mercury  or 
the  iodide  of  potassium. 

You  will  notice,  gentlemen,  that  including  the 
primary  stage  of  quiescence,  I  have  described  four 
apparent  stages  of  incubation,  while  ordinarily 
there  are  described  but  two,  one  of  which  precedes 


76  Lectures  on  Syphilis. 

the  development  of  the  chancre,  and  is  termed  a 
period  of  true  incubation,  and  the  other  deemed  by 
some  a  true,  and  by  others  an  apparent  period  of 
incubation,  intervening  between  the  primary  and 
secondary  syphilitic  manifestations.  1  think,  how- 
ever, that  on  careful  consideration,  the  stages,  or 
rather  intervals  which  I  have  described,  will  be 
sufficiently  plain. 

At  the  end  of  about  forty  to  forty-five  days  on 
the  average,  after  the  development  of  the  initial 
lesion,  the  period  of  "general  systemic  infection 
and  localized  cell  accumulation"  begins,  the  cells 
having  now  reached  their  final  destination.*  The 
first  evidence  of  the  general  infection,  consists  in 
the  development  of  a  peculiar  eruption  of  rose 
colored  spots,  termed  the  syphilitic  roseola.  Al- 
though this  eruption  may  escape  observation,  it  is 
probably  constant,  being  always  present  in  a  greater 
or  less  degree;  in  some  cases  lasting  for  a  number 
of  weeks,  probably  from  two  to  eight,  while  in 
others  it  may  last  only  a  few  hours.  In  its  general 
appearance,  this  eruption  is  not  very  unlike  the 
eruption  of  measles.  The  spots  are  of  a  dull  rose 
red  hue  and  disappear  on  pressure,  when  recent, 
but  later  on,  leaving  a  coppery  stain.  Violent 
exercise,  as  in  running  or  dancing,  is  liable  to 
hasten  or  determine  the  eruption,   as  is  the  case 

*Vide  Otis  "Class  room  lessons  in  Syphilis." 


Lydston.  77 

with  simple  roseola.  There  is  usually  no  pain  or 
other  premonitory  symptom  with  this  eruption,  al- 
though such  symptoms  as  a  facial  neuralgia,  or 
severe  pain  in  the  chest  may  be  observed,  and  in 
some  cases  general  malaise,  headache,  and  febrile 
movement,  may  occur;  these  symptoms  being  sup- 
posed by  some,  to  be  constant,  and  hence  termed 
•'the  syphilitic  fever."  I  have  had  recently  a  case 
in  which  severe  facial  neuralgia  attended  the  rose- 
ola, and  another  in  which  all  the  subjective  symp- 
toms of  an  impending  pneumonia  were  present,  the 
thoracic  pain  being  especially  severe,  and  these 
symptoms  being  followed  by  the  finest  kind  of  a 
roseola  the  next  morning;  as  will  be  seen  hereafter, 
however,  I  believe  these  symptoms  to  have  been 
merely  coincidental.  Sometimes  the  eruption  con- 
sists of  but  a  few  pale  spots,  while  in  others  it  is 
generally  well  marked,  being  occasionally  slightly 
elevated. 

Now,  the  general  idea  prevails  that  the  syphilitic 
roseola  is  the  result  of  local  changes  in  the  skin, 
produced  by  the  syphilitic  poison,  and  reasoning  a 
priori  from  the  line  of  argument  which  I  have  my- 
self given  you,  you  might  be  led  to  the  conclusion 
that  it  is  due  to  a  localized  cell  accumulation,  the 
product  of  which,  collecting  in  the  skin  itself,  con- 
stitutes the  exanthem.     This  is  not  the  case,  how- 


78  Lectures  on  Syphilis. 

ever,  and  it  is  the  only  instance  of  the  kind, 
throughout  the  course  of  syphilis.  The  syphilitic 
roseola  is  due  to  dilatation  of  the  capillaries,  with 
subsequent  stasis,  and  the  exudation  of  leucocytes 
and  red  blood  corpuscles  into  the  implicated  integ- 
umentary area.  ^  The  greater  the  degree  of  stasis^ 
the  larger  the  number  of  extravasated  red  corpicscles^ 
and  inasmuch  as  it  is  due  to  the  changes  in  the  hlood 
jpigmeni  that  staining  of  the  tissues  occurs^  the 
greater  the  nuiiiber  of  hlood  corpuscles  extravasated^ 
the  deeper  and  more  persistent  this  staining  is  likely 
to  he.  We  find  a  similar  staining  in  any  lesion, 
specific  or  simple,  in  which  there  exists  long  con- 
tinued congestion.  This  is  illustrated  by  the 
changes  in  the  tissues  resulting  from  non-syphilitic 
ulcers  of  the  leg.  Now  it  next  remains  to  consider 
the  origin  of  this  capillary  dilatation,  and  inasmuch 
as  the  contractility  of  the  blood  vessels  is  presided 
over  by  the  sympathetic  system,  or  more  properly, 
by  the  ■  vaso-motor  system  of  the  sympathetic,  it 
is  evident  that  vascular  dilatation  in  syphilis  must 
be  due  to  some  peculiar  influence  wrought  upon 
the  sympathetic  system,  by  the  syphilitic  cells, 
which  causes  a  suspension  of  the  contractile  power 
of  the  vascular  walls,  and  leads  to  dilatation  and 
stasis  at  the  periphery.  That  the  calibre  of  the 
capillaries  depends  upon  nervous  currents  from  the 

*Bauiiiler. 


Lydston.  79 

sympathetic,  is  illustrated  by  the  familiar  physiolo- 
gical demonstration,  of  section  of  the  cervical  sym- 
pathetic, which  gives  rise  to  reddening  and  turge- 
scence  of  the  ear  of  the  rabbit,  as  well  as  various 
nutritive  changes  in  the  cornea  of  the  eye,  etc.  It 
is  possible  that  the  dilatation  and  stasis  is  a  reflex 
phenomenon,  and  due  to  the  reflected  local  irrita- 
tion produced  by  the  syphilitic  cells,  but  such  an 
explanation  is  hardly  as  rational  as  that  involving 
a  direct  influence  upon  the  sympathetic  centres, 
analogous  to  that  produced  by  various  drugs,  such 
as  quinine,  belladonna  and  others,  and  to  that  pro- 
duced by  emotional  disturbances. 

I  have  said  something  in  reference  to  the  so- 
called  syphilitic  fever,  but  will  say  a  few  words 
more  upon  that  subject.  Among  the  prodromata 
which  may  be  observed  prior  to  the  development 
of  the  roseola,  are  malaise,  headache,  rheumatoid 
pains,  anorexia,  nausea,  prostration,  sleeplessness, 
and  nervous  irritability,  and  in  some  cases  quite 
sharp  febrile  movement,  followed  perhaps  by  per- 
spiration. These  are  the  symptoms  several  or  all 
of  which  may  be  included  under  the  head  of 
'  'syphilitic  fever"  or  as  Diday  more  correctly  terms 
them  "syphilitic  prodromes."  On  reviewing  the 
list  of  single  symptoms  which  may  occur,  it  will  be 
evident  that  they  may  be  dependent  upon  so  many 


80  Lectukes  on  Syphilis. 

and  various  coincident  disturbances,  that  there  can 
be  no  great  constancy  or  certainty  about  their  oc- 
currence in  syphilis,  and  that  the  term  "syphilitic 
fever"  is  consequently  inaccurate.  M.  Ricord  de- 
nies its  relation  to  syphilis,  and  claims  that  in 
every  case,  it  can  be  traced  to  causes  independent 
of  the  roseola.  Otis  endorses  this  view,  and  from 
my  own  personal  experience  I  am  inclined  to  agree 
with  it,  for  I  have  found  that  febrile  disturbance  is 
exceptional,  and  that  in  my  own  practice  my  pa- 
tients usually  discover  the  roseola  entirely  by  acci- 
dent, or  in  their  daily  examination  of  the  surface 
of  the  body,  and  but  rarely  have  the  slightest  con- 
stitutional disturbance.  Very  often  the  roseola 
escapes  the  patient's  observation  until  I  direct  his 
attention  to  it,  and  then  he  usually  is  much  aston- 
ished that  he  should  feel  perfectly  well,  with  such  a 
prominent  eruption.  With  this  roseola  or  shortly 
after  it,  in  cases  in  which  it  has  not  occurred  prior 
to  the  appearance  of  the  eruption,  general  enlarge- 
ment of  the  lymphatic  glands  occurs,  the  cells  at 
this  time  not  only  having  reached  the  general  lym- 
phatic system,  which  is  extremely  susceptible  to 
their  morbific  influence,  but  being  moreover  unus- 
ually active. 

Just  about  the  time  the  roseola  appears,  some- 
times shortly  before  or  after  it,  we  have  the  devel- 


Lydston.  81 

opnient  of  an  inflammatory  engorgement  of  the 
tonsils,  pharynx,  and  soft  palate,  involving  usually 
the  whole  faucial  surface.  Now,  we  must  seek  for 
an  explanation  of  this  localization  of  the  morbid 
effects  of  syphilis,  in  the  throat,  and  a  simple  one  is 
easily  found.  According  to  Frey,  His,  Reckling- 
hausen and  Teichmann,  the  tonsil  is  a  part  of  the 
general  lymphatic  system,  representing  the  simplest 
form  of  lymphatic  gland.  There  is  no  direct  com- 
munication between  the  tonsillar  follicles  and  the 
adjacent  lymphatic  vessels,  but  each  follicle  is  seen 
to  be  invested  with  an  exceedingly  dense  network 
of  fine  lymphatic  vessels,  which  are  dilated  in  a 
peculiar  fashion  and  cover  in  the  follicle  so  com- 
pletely, that  but  one  small  portion  of  its  surface  is 
free,  this  being  directed  towards  the  mucous  mem- 
brane. The  entire  pharynx  is  exceedingly  rich  in 
lymphatics,  hence  we  might  quite  naturally  expect 
morbid  changes  in  its  structures,  simultaneously 
with  those  occurring  in  the  general  lymphatic  sys- 
tem. This  arrangement  of  the  lymphatics  also 
explains  another  phenomenon,  viz.,  the  occurrence 
of  those  severe  and  often  seriously  destructive  ul- 
cerations, which  occur  in  this  situation  in  late 
syphilis.  These  lymphatics  are  brought  into  much 
more  intimate  relations  with  the  contiguous  blood 
vessels,  than  are  the  lymphatics  of  a  higher  order, 


82  Lectures  on  Syphilis. 

and  are  hence  prone  to  true  inflammation,  and  pro- 
fomid  nutritive  disturbances,  whenever  they  be- 
come crowded  with  the  syphilitic  cells. 

The  next  thing  observable  after  the  roseola,  in 
the  natural  course  of  syphilis,  is  the  development 
of  an  eruption  of  true  papules.  This  may  appear 
when  a  roseola  has  not  been  noticed,  or  may  even 
be  coincident  with  it,  but  generally  follows  it  after 
a  variable  interval,  often  some  weeks  or  months. 
The  papules  are  usually  most  prominent  about  the 
borders  of  the  hair  upon  the  forehead,  forming  a 
peculiar  appearance  termed  the  '  'corona  veneris, " 
or  venereal  crown,  but  may  be  scantily  scattered 
over  the  breast,  back,  and  limbs.  In  still  other 
instances  they  may  be  thickly  studded  all  over  the 
body.  This  eruption  lasts  longer  than  the  roseola, 
occasionally  remaining  prominent  for  a  number  of 
months.  It  is  at  first  of  a  tolerably  bright  reddish 
hue,  but  this  gradually  fades,  leaving  the  charac- 
teristic ham  color.  The  papules  tend  to  exfoliate 
epithelial  scales,  especially  at  their  bases,  forming 
a  peculiar  appearance  known  as  the  collarette  of 
Biette,  a  sign  which  is  supposed  by  some  to  be 
pathognomonic  of  syphilis.  It  is  undoubtedly  char- 
acteristic when  present,  but  unfortunately  it  is 
oftener  absent.  This  shedding  of  epithelial  cells 
around  the  base  of  the  papule  of  syphilis,  is  simply 


Lydston.  83 

due  to  innutrition  of  the  epithelial  elements  about 
the  base  of  the  papule,  produced  by  the  morbid 
cells  within  it.  This  process  is  precisely  like  that 
which  causes  loss  of  tissue  in  the  initial  lesion,  viz. 
necrobiosis  or  ancBinia  of  tissue^  from  the  pressure  of 
abnormal  cell  infiltration. 

We  will  now  examine  the  syphilitic  papule  more 
minutely:  According  to  Kohn,  the  papule  is  com- 
posed of  a  dense,  circumscribed,  cellular  infiltration 
into  the  papillae  and  corium.  This  accumulation 
of  cells  is  piled  up  in  dense  and  regular  layers 
around  the  vessels,  and  in  the  meshes  of  the  con- 
nective tissue.  These  cells  do  not  become  perma- 
nently organized,  but  tend  to  undergo  granular 
and  fatty  degeneration,  and  finally  disappear  en- 
tirely, the  detritus  produced  by  their  retrograde 
metamorphosis,  being  removed  by  the  absorbents, 
to  be  eliminated  by  the  various  emunctories.  Or, 
the  cells  may  become  heaped  together  in  large 
amount,  and  form  pus.  On  section  of  the  papule, 
we  find  two  lines  of  cells  in  the  corium  and  papil- 
lary layer  of  the  derma,  which  layers  are  glued 
together  quite  firmly,  the  epidermis  being  tightly 
stretched  over  them.  The  hardness  of  the  papule 
is  due  to  the  density  and  dryness  of  the  accumu- 
lated cells,  and  its  color  to  capillary  stasis,  to  any 
effusion  of  coloring  matter  from  the  blood  vessels, 


84  Lectures  on  Syphilis. 

and  possibly,  to  the  color  of  the  neoplasm  itself. 
You  will  observe  gentlemen,  that  the  structure  of 
a  secondary  papule,  is  essentially  that  of  the  initial 
lesion  and  the  primary  glandular  infiltrations. 
Now,  it  remains  to  explain  the  cause  of  this  cir- 
cumscribed collection  of  cells,  or  the  syphilitic 
papule. 

We  have  already  stated  that  the  initial  lesion  is 
due  to  an  accumulation  of  cells,  which  results  from 
a  morbid  impulse  given  to  the  normal  leucocytes 
by  the  degraded  syphihtic  cell,  and  it  would  seem 
a  very  logical  inference  that  we  have  here  in  the 
papule  a  similar  process,  and  such  is  in  fact  the 
case.  But  why  is  it  that  these  cell  accumulations 
occur  in  the  papillae  and  cutis  rather  than  in  other 
situations?  By  reviewing  our  anatomy  and  phy- 
siology a  little,  we  will  be  able  to  explain  it.  The 
blood  containing  the  nutrient  pabulum  upon  which 
the  repair  of  the  tissues  depends,  is  distributed  to 
the  various  tissues  of  the  body  by  the  arteries,  and 
returns,  loaded  with  the  products  of  retrograde  tis- 
sue metamorphosis  by  way  of  the  veins.  There 
must  of  necessity  be  a  certain  amount  of  nutritive 
or  germinal  material  taken  to  the  tissues,  over  and 
above  the  quantity  necessary  for  their  repair,  and 
there  must  be  some  physiological  means  of  restor- 
ing this  to  the  blood.     Such  an  arrangement  does 


Lydston.  85 

in  fact  exist,  and  we  have  interposed  between  the 
arterial  and  venous  systems,  a  system  of  fine  ves- 
sels teiTned  lymphatics,  the  function  of  which  is  to 
collect  all  surplus  germinal  material,  and  return  it 
to  the  circulation.  The  nearest  points  of  contact 
of  the  arterial,  venous  and  lymphatic  vessels  are  at 
the  superficies,  or  the  periphery  of  the  body,  where 
the  capillaries  of  the  general  circulatory  and  lym- 
phatic systems  are  in  most  intimate  contact,  and  as 
it  is  here  that  the  vessels  are  smallest,  it  is  natur- 
ally in  this  situation  that  retardation  of  the  circula- 
tion is  most  likely  to  occur,  or  an  interference  with 
the  interchange  of  nutritive  materials,  result  from 
exciting  causes  of  various  kinds.  It  is  here,  there- 
fore, that  we  should  expect  to  find  collections  of 
surplus  germinal  material  which  from  any  cause 
had  been  forced  to  accumulate  in  the  tissues,  and 
failed  to  find  an  entrance  into  the  lymphatics. 
Such  is  really  the  case.  You  are  probably  some- 
what familiar  with  the  structure  of  the  papillae  of 
the  cutis,  and  are  aware  that  each  one  contains . 
capillary  lymphatic  and  blood  vessels.  According 
to  Y.  Rindfleish,  Teichmann,  and  others,  the  lym- 
phatic plexus  lies  in  the  centre  of  the  papilla,  while 
the  capillary  blood  vessels,  wind  corkscrew  fashion 
around  it  until  they  reach  the  apex.  Teichmann, 
in  particular,  has  called  attention  to  this  peculiar 


86  Lectures  on  Syphilis. 

arrangement.  These  vessels  vary  in  size  from  time 
to  time,  and  vary  according  to  the  degree  of  vascu- 
lar or  blood  pressure.  It  is  in  the  spaces  hetween 
these  capillary  loops  and  the  central  lymphatics^  that 
the  accumulation  of  cells  in  the  syphilitic  pap)ule 
tahes  p>lace.  An  extra  number  of  cells  is  brought 
to  the  part,  and  in  addition,  there  is  an  increased 
local  proliferation  which  temporarily  blocks  up  the 
lymphatics,  or  overcomes  their  power  to  dispose  of 
surplus  germinal  material,  and  as  a  result,  we  have 
a  heaping  up  of  cells,  with  all  those  attendant  mor- 
bid phenomena  which  we  have  seen  in  the  initial 
lesion.  Sometimes  the  papules  are  very  fine,  but 
they  may  become  large,  sometimes  by  fusion,  or 
may  involve  sebaceous  and  sudariparous  glands, — 
which  have  no  lymphatics, — simply  by  matting 
them  into  the  general  infiltration  of  a  number  of 
papillae.  As  a  result  of  this  same  cell  process,  we 
may  have  at  any  time  during  the  period  of  general 
syphilis,  usually  during  the  early  months  of  the  se- 
condary period,  often  co-existent  with  the  papular 
eruption,  falling  of  the  hair,  or  alopecia.  This  re- 
sults from  a  derangement  of  nutrition,  produced  by 
a  cellular  infiltration  of  the  hair  follicles.  As  a  re- 
sult of  spontaneous,  or  therapeutically  induced  fatty 
degeneration,  this  cell  accumulation  may  be  re- 
moved, and  the  hair  again  grow.     The  nails  of  the 


Lydston.  87 

fingers  and  toes  may  become  affected  by  this  same 
cellular  infiltration,  and  become  brittle  and  lustre- 
less, or  from  very  great  infiltration  and  consequent 
nutritive  disturbances,  the  destructive  lesion  known 
as  syphilitic  onychia  may  occur.  I  have  already 
stated  that  pustules  or  vesicles,  may  form  during 
the  papular  stage  of  syphilis.  Ulcerations  resem- 
bling tertiary  or  late  secondary  lesions  may  also 
occur.  These  changes  apparently  result  from  a 
lack  of  formative  power  in  the  lymph,  or  a  tendency 
to  liquefaction  of  the  hyperplasic  materials,  due  to 
constitutional  debility  or  lack  of  tone. 

There  are  several  peculiar  lesions  occurring  dur- 
ing the  period  of  general  syphilis  which  are  both 
important  and  interesting,  but  which  are  really 
mere  modifications  of  the  syphilitic  papule  depend- 
ent mainly  upon  the  situation  and  surroundings  of 
the  lesion.  Mucous  patches  which  appear  upon 
the  various  mucous  surfaces  or  quasi  mucous  sur- 
faces, where  they  are  constantly  subjected  to  irrita- 
tion from  friction,  and  to  heat  and  moisture,  are 
examples.  These  lesions  are  elevated  plaques  of 
a  milky  or  grayish  color,  covered  with  a  grayish 
exudate,  and  are  not  greatly  unlike  the  primary 
superficial  erosion  sometimes  seen  upon  the  geni- 
tals. When  situated  about  the  anus,  upon  the 
scrotum,    vulva,    or    between    the    digits,    these 


88  Lectures  on  Syphilis. 

''plaques  muqueuse"  tend  to  become  hypertrophied, 
forming  broad  papules  or  excrescences  more  or  less 
elevated,  sometimes  covered  with  a  sort  of  diph- 
theritic deposit,  and  usually  seereting  a  foul-smell- 
ing serous  secretion.  These  modified  mucous 
patches  are  termed  mucous  tubercles,  or  condy- 
lomata. The  existence  of  local  irritation  often 
determines  the  development  of  mucous  patches,  as 
is  seen  in  the  mouth,  from  the  contact  of  a  pipe 
stem,  or  from  irritation  of  the  mucous  membrane 
of  the  mouth  or  tongue  by  a  broken  tooth.  Tobac- 
co smoke  from  either  pipe  or  cigars,  and  tobacco 
juice,  will  also  produce  these  patches,  and  it  will 
be  found  much  easier  to  prevent  them  by  remov- 
ing sources  of  local  irritation,  than  to  remove  them 
when  once  they  have  formed. 

During  this  period  we  often  have  ocular  troubles, 
which  may  prove  of  very  serious  import.  An  in- 
filtration of  cells  into  the  iris  and  ciliary  body 
often  sets  up  an  iritis  at  this  time,  this  inflamma- 
tion being  really  in  no  way  distinguishable  from 
that  produced  in  the  same  situation  by  rheumatism, 
trauma  or  other  exciting  causes.  There  is  perhaps 
a  greater  tendency  to  chronicity  and  plastic  exu- 
date, with  the  formation  of  adhesions  or  synechise, 
and  the  iris  is  possibly  a  trifle  more  cloudy  and 
infiltrated  than  in  the  simple  forms  of  iritis,  but 


Lydston.  89 

the  differences  if  any  exist,  are  too  slight  as  a  gen- 
eral rule  to  be  of  very  great  practical  importance 
from  a  diagnostic  stand-point.  The  local  accumu- 
lation of  cells  in  these  cases,  sometimes  forms  a 
distinct  nodule  or  tumor  often  termed  the  '  'gummy 
tumor  of  the  iris,"  but  which  is  in  no  wise  different 
in  structure  from  the  syphilitic  papule.  It  is 
especially  apt  to  occur  in  late  syphilis.  Similar 
plastic  nodules  may  form  in  the  choroid  at  this 
period.  Bone  pains,  usually  localized,  and  localized 
subperiosteal  accumulations  of  cells  termed  nodes, 
frequently  occur  during  this  time.  The  pain  in 
these  instances  is  due  to  intra-osseous  or  sub-perios- 
teal  pressure,  produced  by  the  dense  accumulations 
of  cells. 

Now  gentlemen,  I  think  we  have  given  sufficient 
attention  to  the  pathology  of  active  or  general 
syphilis,  to  enable  you  to  understand  its  various 
phenomena  pretty  thoroughly,  and  to  demonstrate 
clearly  to  you  this  one  important  point,  an  accept- 
ance of  which  will  enable  you  to  understand  syph- 
ilis under  all  forms,  and  in  the  greatest  variety  of 
its  pathological  phenomena,  viz:  That  all  patho- 
logical manifestations  due  to  syphilis  occurring 
during  the  active  period  of  the  disease^  which  lasts 
usually  from  six  to  eighteen  months^  are  each  and 
every  one  due  to  a  localized  cell  accumulation  and 


90  Lectures  on  Syphilis. 

proliferation^  and  to  nothing  else^  and  that  an  intel- 
ligent appreciation  of  this  fact  will  alone  form  a. 
rational  basis  for  the  treatment  of  the  disease^  which 
is  alike  in  every  case^  and  consists  simply  of  all 
those  means^  whether  general  or  locals  which  tend  to 
produce  fatty  degeneration  or  retrograde  metamor- 
phosis in  the  hyperplastic  materials  and  induce 
their  elimyination  from  the  hody^  while  at  the  same 
tim,e  tending  to  improve  the  general  health  of  the 
patient.  Quite  a  long  proposition,  but  necessarily 
so,  for  it  contains  the  whole  subject  of  syphilis 
within  a  comparatively  small  space.  The  only 
distinguishing  characteristic  of  the  syphilitic  cell 
as  contrasted  with  the  normal  germinal  cell,  is  its 
contagiousness,  which  consists  in  its  power  of  im- 
parting to  normal  leucocytes,  its  own  tendency  to 
proliferation,  hy  which  as  we  have  seen  it  is  charac- 
acterized.  This  rapid  proliferation  does  not  usually 
cause  destruction  of  tissue,  but  gives  rise  to  phe- 
nomena which  a  p>riori  we  might  expect  from  an 
accumulation  of  surplus  nutritive  material.  This 
cell  accumulation  obstructs  the  tissues  for  a  time, 
in  uncomplicated  cases,  and  then  from  prolonged 
pressure,  innutrition  and  general  causes,  it  under- 
goes fatty  metamorphosis  and  is  finally  eliminated 
by  the  various  emunctories. 

According  to  Baiimler,  the  infection  of  syphilis 
lasts   from   eighteen  months  to  two  years,   after 


Lydston.  ^  91 

which  it  is  exhausted.  After  the  cessation  of  the 
active  period  of  syphilis,  the  blood  and  the  secre- 
tions of  open  lesions  cease  to  be  contagious,  and  it 
may  also  be  stated  that  in  by  far  the  greater  pro- 
portion of  cases,  especially  if  they  have  been  pro 
perly  treated,  no  further  manifestations  of  syphilis 
are  ever  experienced.  Reasoning  from  these  facts, 
it  is  quite  logical  to  infer  that  the  so-called  tertiary 
period  of  syphilis  to  Avhich  I  will  hereafter  call 
your  attention,  is  not  a  stage  of  the  disease  at  all, 
but  is  simply  a  period  of  generally  unnecessary 
sequelae,  and  indeed,  such  is  now  the  teaching  of 
our  best  authorities  upon  the  subject.  Hutchin- 
son, Lee,  Lome,  Baiimler,  Besiadecki,  Otis,  and 
many  others  incline  to  this  view.  And  for  my 
own  part,  I  think  that  the  list  of  cases  of  tertiary 
syphilis  or  sequelae  may  be  considerably  narrowed, 
if  we  remember  that  some  of  them  may  be  suffering 
from  the  excessive  or  injudicious  action  of  mercury, 
rather  than  from  the  sequelae  of  syphilis. 


Lecture  Y. 

Period  of  sequelae,  or  so-called,  tertiary  stage. — The  tubercular  syph- 
ilide. — Syphilomatous  lesions.— Structure  of  syphiloma.— Favorite 
sites  for  development  of  syphilomata. — Tendency  to  necrosis  and  ul- 
ceration of  tertiary  deposits.— Non-infectiousness  of  tertiary  lesions. 
— Normal  character  of  the  cells  of  gummy  deposits.  -Causes  of  gummy 
deposits. — Lymphatic  obstruction.— Cause  of  the  tendency  to  recur- 
rence during  stage  of  sequelae.- Ordinary  division  of  syphilis  into 
stages.— Precocious  and  malignant  syphilis.— The  syphilides;  their 
characteristics,nomenclature,andconcomitant  symptoms. -Syphilitic 
ecthyma  and  rupia.— Syphilitic  pigmentation  and  cicatrices.— Dura- 
tion of  syphilis  as  a  whole.— Insidiousness  of  syphilis.— Probationary 
period  of  syphilitics  intending  to  man-y.— Bearing  of  hygienic  sur- 
roundings upon  severity  of  syphilis.— Illustration  of  malignant 
syphilid.— Character  of  early  lesions  influences  prognosis.— A  typical 
case  of  syphilis. 

Gentlemen: — Having  finished  our  description 
of  the  lesions  of  the  secondary  or  active  period  of 
syphilis,  and  having  given  the  physio-pathological' 
explanation  of  the  various  phenomena  presented 
by  that  period  of  the  disease  during  which  we  have 
general  constitutional  infection  and  localized  cell 
accumulations,  it  only  remains  for  us  to  consider 
the  period  of  sequelae,  or  the  so-called  "tertiary 
stage. " 

One  of  the  most  frequent  and  important  of  the 
tertiary  lesions  or  sequelae,  is  the  tubercular  erup- 
tion. This  has  been  said  to  be  due  to  a  localized 
accumulation  of  morbid  material  in  the  tissues,  or 
so-called  "gummy  infiltration,"  which  is  the  basis 
of  all  tertiary  lesions.     This  gummy  material  is 


94  Lectukes  on  Syphilis. 

termed  by  Wagner  "syphiloma,"  and  is  described 
by  him,  as  an  infiltration  of  cells  and  nuclei,  the 
cells  not  being  capable  of  differentiation  from 
the  normal  white  blood  cell  or  leucocyte,  and  the 
nuclei  themselves  presenting  no  characteristic  ap- 
pearances. He  states  that  their  morbid  effects  are 
due  to  a  mere  interference  with  the  function  and 
nutrition  of  affected  parts,  by  simple  pressure. 
Baiimler  also  claims  that  the  histological  elements 
of  syphilomata,  lack  specific  microscopic  charac- 
ters. 

The  tubercular  or  gummy  lesion  may  develop  in 
any  situation,  its  favorite  situations  being  the  cell- 
ular tissue,  skin,  bones,  liver,  testes,  brain  and 
kidneys,  and  in  children  especially,  the  lungs. 
This  gummy  material  is  a  grayish  red,  homogene- 
ous mass  of  greater  or  less  consistency,  which  may 
be  found  in  the  parenchyma  of  any  organ  or  tissue 
of  the  body,  either  as  a  diffused  or  circumscribed 
infiltration,  but  never  encapsulated.  When  this 
accumulation  of  morbid  material  is  superficial,  and 
exposed  to  unequal  pressure,  or  when  it  is  exces- 
sive, or  involves  the  walls  of  the  blood-vessels,  thus 
giving  rise  to  localized  innutrition  from  pressure 
or  vascular  obstruction,  the  whole  mass  is  liable  to 
ulcerate,  or  break  down  into  pus  which  may  absorb 
through  fatty  or  granular  degeneration  without 
ulceration. 


Lydston.  95 

As  we  have  already  seen,  the  lesions  now  linder 
consideration  have  no  specific  inoculable  properties, 
this  view  being  supported  by  Ricord,  Diday,  Bar- 
ensprung  and  Baiimler.  This  is  the  only  differ- 
ence so  far  determined,  between  the  histological 
elements  of  the  tertiary,  and  those  of  the  secondary 
lesions,  save  perhaps  the  greater  tendency  to 
destruction  of  tissue  in  the  former.  Now,  it  has 
been  demonstrated  that  the  longer  the  duration  of 
the  secondary  stage,  and  consequently  the  more 
pronounced  the  changes  in  the  lymphatic  struc- 
tures, produced  by  the  lesions  of  the  active  stage, 
the  greater  the  liability  to  tertiary  lesions  of  a 
severe  type.  As  the  cells  composing  the  gummata 
are  not  infectious,  and  are  less  active  than  the 
true  syphilitic  germinal  cell,  they  are  probably  not 
the  result  of  the  action  of  a  virus  or  poison  upon 
the  normal  tissue  elements,  but  are  due  to  lym- 
phatic obstruction,  being  no  more  nor  less  than  an 
accumulation  of  normal  embryonal  cells,  which  are 
prone  to  undergo  and  produce  various  degenerative 
changes  through  nutritive  disturbances.  The  lym- 
phatic obstruction  giving  rise  to  this  accumulation 
of  embryonal  cells,  is  the  result  of  injury  to  the 
absorbents  produced  by  the  lesions  of  the  active 
stage.  Kindfleisch,  w^ho  is  unexcelled  as  an  au- 
thority on  pathological  questions,  says:     "Luxuri- 


96  Lectures  on  Syphilis. 

ous  new  formations,  catarrhs  and  surface  secretions 
of  various  kinds,  must  be  produced  when  the 
lymph  conveyance  is  hindered."  Now  the  results 
of  scientific  investigation  tend  to  show  that  the 
new  formations  and  surface  secretions  of  tertiary 
syphilis,  are  all  due  to  an  accumulation  of  normal 
germinal  material,  and  if  this  be  true  how  else  can 
we  account  for  it,  except  by  the  existence  of  lym- 
phatic obstruction?  A  very  important  fact  bear- 
ing out  this  theory,  is  that  the  treatment  of  ter- 
tiary lesions  is  the  same  throughout,  whatever 
the  lesion,  and  consists  in  the  administration 
of  mercury  and  the  iodide  of  potassium.  Ac- 
cepting the  view  of  the  formation  of  the  gum- 
mata  or  syphilomata,  which  has  been  set  forth, 
the  term  "gummy  period,"  applied  by  some,  is 
inaccurate,  and  the  term  "period  of  lymphatic 
obstruction"  suggested  I  believe,  by  Otis,  is  more 
proper, ;  as  indicating  the  actual  pathological  con- 
dition present,  and  the  exact  manner  of  its  produc- 
tion. 

After  the  removal  of  the  cells  by  fatty  degenera- 
tion, there  is  always  a  tendency  to  recurrence, 
which  explains  the  difficulty  of  curing  the  disease 
at  this  period.  This  tendency  is  due  to  an  increased 
injury  to  the  lymphatic  structures,  which  were  al- 
ready greatly  impaired  by  the  lesions  of  the  active 


Lydston.  97 

stage  of  syphilis.  This  impairment  consists  in  a 
formation  of  fibrous  tissue,  as  a  result  of  low  in- 
flammatory action,  mechanically  set  up  by  the 
cells.  This  fibrous  formation  of  course  interferes 
in  a  measure  with  tissue  nutrition  in  diflferent 
localities,  by  producing  changes  in  the  vascular 
walls,  and  it  is  claimed  by  some  that  a  great  deal 
of  the  trouble  in  so-called  tertiary  syphilis,  is  due 
to  wide-spread  fatty  degeneration  caused  by  this 
same  vascular  contraction.  In  any  event  these 
vascular  changes  do  produce  innutrition,  and  a 
tendency  to  destructive  changes  in  those  parts  sup- 
plied by  the  afiected  vessels,  and  the  nutrition  of 
which  is  still  further  impaired  by  local  pressure  from 
accumulation  of  lymphatic  elements.  It  is  well- 
known  that  fatty  and  purulent  degeneration  are 
more  likely  to  occur  in  some  subjects  than  in  others, 
and  are  most  likely  to  supervene  in  individuals 
who  are  cachectic  or  debilitated  from  any  cause. 
Debility  would  of  course  be  produced  by  a  pro- 
longed and  severe  active  stage,  and  indeed,  Hutch- 
inson claims,  '  'that  the  liability  to,  and  severity  of, 
tertiary  lesions,  are  in  direct  proportion  to  the 
duration  and  severity  of  the  secondary  stage." 

Now,  gentlemen,  the  conclusion  at  which  we  may 
arrive  after  a  careful  consideration  of  all  the  facts 
which  I  have  endeavored  to  present  to  you,  is  this: 


98  Lectures  on  Syphilis. 

That  the  various  lesions  and  different  degrees  of 
severity  of  the  lesions  of  the  so-called  "tertiary 
stage  of  syphilis,"  depend  upon,  first,  the  amount 
of  damage  produced  by  the  lesions  of  the  active 
period  of  the  disease,  and  its  duration,  and  secondly, 
upon  the  constitutional  condition  of  the  individual, 
independently  of  any  specific  virus. 

I  have  not  yet  given  you  the  division  ordinarily 
made  of  syphilis,  deeming  it  best  to  first  give  you 
an  idea  of  its  "physiological  pathology."  As  I 
have  already  stated  in  a  general  way,  syphilis  is 
ordinarily  and  somewhat  arbitrarily  divided  into 
the  so-called  "primary,"  "secondary" and  "tertiary 
stages,"  and  by  some  an  "intermediary"  stage  is 
described  which  comprises  the  lull,  or  at  most  the 
period  of  almost  insignificant  lesions  following  the 
active  period,  and  prior  to  the  development  of  the 
tertiary  stage.  "Primary  syphilis"  of  course  im- 
plies the  initial  lesion  with  its  attendant  glandular 
enlargements.  '  'Secondary  syphilis"  comprises  the 
earlier  affections  of  the  skin  and  mucous  surfaces, 
and  many  of  the  lighter  changes  in  the  eye,  testis 
and  other  glands,  with  some  forms  of  nervous  mani- 
festations. '  'Tertiary  syphilis"  comprises  the  later 
severe  ulcerative  skin  lesions,  the  deeper  lesions 
of  connective  tissue,  bone,  muscle,  cartilage  and 
the  viscera,  and  all  the  severe  lesions  of  the  eye, 


Lydston.  99 

testis,  and  brain;  in  short,  all  of  those  many  and 
various  changes,  characterized  by  the  so-called 
"gummy  deposit."  The  line  between  the  two 
stages  is  not  always  clear,  but  in  typical  cases  the 
lesions,  at  first  superficial,  gradually  increase  in 
severity  to  the  destructive  pathological  changes  of 
the  so-called  tertiary  stage  or  period  of  sequelae. 
Some  of  the  lesions  properly  belonging  to  the  sec- 
ondary group  are  liable  to  crop  out  with  the  ter- 
tiary lesions,  and  rarely  on  the  other  hand,  nodes 
develop  in  the  secondary  stage.  "^  In  quite  rare  and 
malignant  cases,  the  secondary  stage  may  appear 
to  be  omitted  entirely,  destructive  lesions  ordinarily 
characterizing  the  tertiary  period,  appearing  in  a 
few  months  after  the  chancre.  These  varieties  of 
cases  include  or  comprise  the  cases  of  so-called 
irregular  and  malignant  syphilis. 

Secondary  syphilis  lasts  often  a  year  and  some- 
times two  or  more.  I  have  already  stated  that  the 
active  period  of  syphilis  has  a  duration  of  from 
eighteen  months  to  two  years,  but  there  need  not 
necessarily  be  manifestations  of  the  disease  during 
that  time.  You  will  understand,  gentlemen,  that 
the  division  of  the  stages  or  periods  of  syphilis 
involved  in  the  physiological  pathology  that  has 
been  given  you,  is  based  upon  pathological  changes 

♦Osseous  and  subperiosteal  swellings  do  develop  during  the  sec- 
ondary stage,  but  characteristic  nodes  are  exceptionally  seen. 


100  Lectures  on  Syphilis. 

altogether,  and  not  upon  mere  symptomatology,  as 
is  ordinarily  done.     You  will  thus  appreciate  the 
fact  that  the  so-called  secondary  stage,  as  ordinar- 
ily given,  is  merely  that  portion  of  the  "active 
period"  during  which  actual  lesions  are  present. 
The  division  of  the  disease  into  primary,  secondary, 
and  tertiary  stages,  depends  upon  the  form  of  the 
lesions,  and  is  therefore  necessarily  inaccurate  and 
unscientific,  while  the  more  rational  division  into 
the  "initial"  and  "active"  periods  and" period  of 
sequelse"   is    founded   upon   a   knowledge   of  the 
natural  course  of  the  disease  in  the  tissues,  the 
lesions  being  dependent  upon  this  natural  course, 
and  not  vice  versa.     Tertiary   syphilis  does  not 
commence  until  at  least  one  year  after  the  initial 
sore,  excepting  in  cases  of  malignant  syphilis.     As 
I  have  endeavored  to  show  you,  it  is  not  a  neces- 
sary stage  of  syphilis  at  all,  and  does  not  appear  in 
by  far  the  largest  number  of  cases.     It  may,  how- 
ever, appear  after  years  of  apparent  good  health. 
The  whole  secondary  stage  is  sometimes  skipped, 
especially  under  treatment,  and  no  manifestations 
of  general  syphilis   appear  until   suddenly   some 
tertiary  lesion   of  a  greater   or  less   severe  type 
develops.     These  cases  are  rare,   and  it  must  be 
remembered  that  there  is  a  possibility  of  even  some 
of  these,  being  due  to  too  much  Doctor  Hydrarg.    I 


Lydston,  101 

have  seen  quite  recently  two  cases  in  which  three 
and  nine  years  respectively  had  elapsed  since  the 
primary  sore,  during  which  time  no  secondary 
symptoms  ever  appeared,  and  in  which  true  gummy 
ulceration  existed. 

The  most  prominent  of  the  manifestations  of 
syphilis  are  the  eruptions  of  the  skin,  which  are 
termed  "syphilides"  or  "  syphilodermata. "  These 
are  many  and  various;  but  their  classification  may 
be  rendered  quite  simple,  thus:  if  papules  are  the 
most  prominent  lesion  we  term  it  a  "  papular  syph- 
ilide."  In  the  same  way  we  have  the  vesicular, 
pustular,  tubercular,  scaly  or  squamous,  and  ulcer- 
ative syphilides,  and  such  combinations  as  papulo- 
pustular,  papulo-squamous  syphilides,  and  so  on. 
Ulcerative  syphilides  may  be  desis'nated  as  super- 
ficial, deep,  serpiginous,  or  perforative,  as  the  case 
may  be. 

The  most  important  thing  with  reference  to 
syphilides  is  the  consideration  of  their  general 
characteristics.  They  are:  1st,  polymorphism  of 
the  chancre;  2nd,  rounded  form  of  the  eruptive 
lesions  and  ulcers;  3rd,  lividity  or  ham  color, 
becoming  coppery,  then  grayish,  and  finally  white 
and  shining;  4th,  absence  of  pruritis  and  pain; 
5th,  symmetry,  generalization  and  superficial 
character  of  the  early  eruptions;  6th,  tendency  to 


102  Lectures  on  Syphilis. 

grouping  of  later  eruptions,  which  involve  the 
true  skin  and  tend  to  scarring;  7th,  scales 
white,  generally  superficial  and  non-adherent ; 
8th,  crusts  irregular,  thick  and  adherent,  and 
either  of  a  greenish  or  black  color;  9th,  abrupt 
edges  of  ulcerations,  which  are  not  undermined, 
are  sluggish,  and  bleed  easily;  10th,  the  rounded, 
depressed  appearance  of  the  cicatrix,  which  is  thin, 
movable  upon  the  sublying  tissues,  pigmented  at 
first  sometimes,  but  eventually  becoming  white  and 
shining.^  In  addition  to  these  special  characters 
of  the  lesions  of  syphilis,  we  have  attendant  symp- 
toms, such  as  the  so-called  syphilitic  fever  in  some 
cases,  alopecia,  headache,  osteo-copic  pains  worse 
at  night,  analgesia,  anaesthesia,  indolent  lymphitis, 
iritis,  sore  throat,  and  mucous  patches. 

We  apply  the  term  "polymorphous"  to  the 
syphilides,  for  the  reason  that  there  is  no  form  of 
skin  lesion  which  may  not  occur  in  syphilis,  and 
no  single  form  or  type  of  lesion  is  usually  present, 
e.  g.  a  papular  syphilide  is  rarely  purely  papular, 
vesicles,  pustules,  or  erythematous  patches  being 
usually  found  at  the  same  time,  and  the  eruption 
being  named  from  the  lesion  whicn  predominates. 

The  tendency  of  the  syphilides  to  arrange  them- 
selves in  a  rounded  form,  is  peculiar  and  well- 
marked,  the  later  syphilides  being  especially   dis- 

*Vlde  Van  Buren  and  Keyes. 


Lydston.  103 

posed  to  circular  grouping.  The  color  of  the 
syphilides  is  not  an  inflammatory  red,  but  is  a 
vinous  or  purplish  red,  resembling  the  color  of  raw 
ham,  the  color  gradually  passing  by  pigmentation 
into  a  coppery  hue,  or  more  deeply  to  a  brownish 
or  black  color.  The  pigmentation  may  last  for 
years,  but  finally  clears  off  gradually  from  the 
center  towards  the  periphery,  the  cicatrix  or  spot 
becoming  eventually  white  and  shining. 

Pain  and  pruritus  are  rarely  present  in  uncompli- 
cated syphilides,  excepting  when  irritated  or 
inflamed.  In  dependent  portions  of  the  body,  as 
in  the  legs,  or  in  such  situations  as  the  throat, 
which  are  subjected  to  constant  irritation,  ulcera- 
tions are  liable  to  be  quite  painful.  When  an 
eruption  that  is  evidently  syphilitic  gives  rise 
to  pain  and  itching,  we  can  usually  find  some 
cause  of  irritation  independent  of  the  syphilide. 
The  patient  may,  perhaps,  have  an  irritable  skin, 
and  a  pruritus  which  constantly  troubled  him  prior 
to  the  development  of  syphilis.  Contrary,  how- 
ever, to  the  general  rule,  the  early  eruptions  of  the 
scalp  are  attended  by  pruritus. 

The  earlier  syphilides  are  superficial,  and  leave 
no  cicatrices,  and  are  symmetrical;  appearing  upon 
the  flanks  and  sides  of  the  trunk,  the  sides  of  the 
neck,    forehead,    etc.      The   later    eruptions   are 


104  Lectures  on  Syphilis. 

grouped  and  not  generalized,  and  are  characterized 
by  destruction  of  tissue,  as  evidenced  by  the  result- 
ing cicatrices.  They  may  leave  scars,  even  if  no 
ulceration  occurs,  which  is  true  of  no  other  lesion 
excepting  the  scrofulides,  of  which  the  lupus  non- 
exedens  is  an  example,  but  w^hich  leaves  an  irreg- 
ular burn-like  scar.  The  scales  of  the  squamous 
syphilide  are  very  thin  and  non-adherent,  not  at 
all  like  the  thick,  imbricated  scales  of  psoriasis. 
The  scabs  of  the  ulcerative  syphilides  are  thick, 
rough,  and  adherent,  dark,  of  a  greenish  black 
color  usuall}^,  but  sometimes  light,  if  the  lesion  be 
simply  pustular.  In  this  connection  I  will  call 
your  attention  to  two  important  varieties  of  syph- 
ilide :  The  first  is  the  syphilitic  ecthyma,  which 
consists  in  an  eruption  of  large  pustules,  which 
soon  scab  over  with  a  characteristic  dark  greenish 
crust.  On  lifting  this  crust,  a  characteristic 
sharply  cut  circular  ulcer  will  be  found.  A  step 
f u  rther,  and  we  have  the  syphilitic  rupia,  in  which 
as  the  crusts  form  they  are  pushed  up  and  replaced 
by  accumulations  of  material  from  beneath,  and 
the  ulceration  gradually  extending  at  its  peripher}^, 
we  soon  have  a  peculiar  appearance  quite  like  an 
oyster  shell  upon  the  surface.  The  crusts  are  piled 
up  in  imbricated  layers,  which  when  lifted  from 
their  bed,  expose  the   results  of  tissue  destruction. 


Lydston.  105 

in  the  shape  of  extensive  ulceration.  These  rupial 
crusts  may  become  very  large,  and  when  numer- 
ous, form  a  most  disgusting  spectacle. 

I  have  already  stated  that  the  ulcerations  of 
syphilis  are  round,  clear  cut,  and  not  unlike  chan- 
chroid.  They  are  sluggish  like  any  chronic  ulcer, 
and  are  painless,  unless  greatly  congested  and 
inflamed,  or  over  a  bone,  the  periosteum  of  which 
is  involved.  Cicatrices  remaining  after  destruction 
of  tissue  by  syphilicles,  whether  there  has  been 
ulceration  or  not,  are  usually  rounded,  thin, 
depressed,  and  movable,  not  adherent.  They  are 
at  first  pigmented,  especially  in  brunettes,  but 
eventually  clear  up  and  become  white  and  shining. 
I-n  strumous  subjects,  in  whom  the  lesion  is  likely 
to  be  a  combination  of  struma  and  syphilis,  the 
resulting  cicatrices  are  apt  to  be  puckered  and 
irregular. 

Now  as  for  the  duration  of  syphilis :  There  is 
no  disease,  the  duration  and  course  of  which  are  so 
uncertain  as  those  of  syphilis  It  is  impossible  to 
state,  in  any  given  case,  that  the  disease  has,  or 
has  not  terminated,  and  this  is  more  especially  true 
when  we  consider  that  it  may  permanently  modify 
the  constitution  of  the  individual,  even  when  no 
actual  manifestations  of  the  disease  appear  after  a 
certain  time.     The  disease  may  manifest  itself  as  a 


106  Lectures  on  Syphilis. 

series  of  mild  secondary  eruptions  followed  by 
apparent  recovery,  or  it  may  afford  no  evidence  of 
its  presence  after  the  initial  sore,  until  late  in  life, 
when  suddenly  tertiary  lesions  or  sequelye  crop 
out.  In  a  laro^e  number  of  cases,  we  must 
acknowledge  that  syphilis  causes  a  permanent 
modification  of  the  patients'  constitution,  still  we 
must  believe  that  syphilis  can  be  cured;  and  my 
own  opinion  is,  that  it  is  a  perfectly  curable  affec- 
tion in  by  far  the  greater  proportion  of  cases,  pro- 
viding the  patient  be  intelligent  and  the  doctor  con- 
scientious. We  have  proof  of  this  in  the.  cases  of 
second  attacks,  cited  by  reliable  authorities,  and  we 
have  already  seen  that  whatever  the  possibilities  of 
tertiary  lesions,  they  are  not  necessary,  and  are 
undoubted!}^  sequelse.  We  find  that  the  patients 
in  the  late  tertiary  period  of  syphilis  may  procreate 
healthy  children,  and  that  the  blood  and  secretions 
of  tertiary  lesions  are  no  longer  inoculable. 

As  found  among  the  better  classes,  syphilis  is  a 
very  insidious  disorder,  and  we  will  meet  with 
innocent  ladies  complaining  of  various  symptoms 
which  are  vaguely  described,  and  as  vaguely  treat- 
ed, as  neuralgic  or  rheumatic,  which  are  no  more 
nor  less  than  slioiit  manifestations  of  old  Proteus, 
and  by  which  they  perhaps  come  honestly  enough. 
Children  may  have  obscure  symptoms  which  mis- 
lead both  parents  and  ph^^sician,  and  which  are 


Lydston.  107 

conveniently  termed  "scrofula"  in  some  instances, 
according  to  my  own  view  of  the  heredity  of  scrof- 
ulosis.  The  old  gentleman  forgets  a  "little  sore" 
he  once  had,  and  never  dreams  of  attributing  the 
little  troubles  ot  his  wife  and  children,  to  those 
dimly  remembered,  and  as  lightly  weighed  wild 
oats  that  he  once  sowed.  But  whether  remembered 
or  not,  the  harvest  garnered  as  the  fruit  of  that 
sowing  is  none  the  less  certain. 

The  practical  question  now  arises:  "  When  is  it 
safe  for  a  person  to  marry  after  having  had  a  chan- 
cre?" On  the  average  we  may  say  three  years,  or 
we  might  fix  the  period  as  eighteen  months  after 
the  disappearance  of  the  last  syphilitic  lesion, 
providing  three  years  have  elapsed,  the  patient 
being  meanwhile  under  careful  treatment,  which  is 
to  be  persisted  in  until  after  the  birth  of  the  first 
child.  During  the  three  years  named,  symptoms 
may  crop  out  at  any  time,  but  under  careful  man- 
agement, they  are  usually  slight,  and  whether  we 
can  call  it  a  cure  or  not,  the  virulence  of  the  disease 
seems  to  be  exhausted  in  cases  of  mild  or  moderate 
severity  so  handled,  in  about  three  years.  If  a 
patient  be  addicted  to  excesses  of  any  sort,  if  he 
does  not  take  a  steady  and  efficient  course  of  treat- 
ment, but  treats  himself — perhaps  to  excess — at 
spasmodic  intervals,  his  chances  are  of  course  not 
very  good. 


108  Lectures  on  Syphilis, 

The  severity  of  syphilis  depends  mainly  upon  the 
constitution  and  hygienic  condition  of  the  patient. 
As  we  have  seen,   we  do  not  have  at  the  present 
day,  such  severe  cases  as  a  general  rule,  as  in  past 
years,  the  reason  for  which  I  have  already  given. 
In  the  better  classes,  it  is  a  very  mild  disease  by 
comparison  with  the  lower  walks  of  life,  in  which 
we  may  still  meet  with  cases  exemplifying  the  ser- 
ious character  of  the  disease.    Even  among  persons 
who  are  constitutionally  and  hygienically  well  cir- 
cumstanced, we  sometimes  see  cases  of  the  most 
malignant  type.      I  well  remember  an  instance  in 
illustration  of  this  fact:  During  last  Summer  I  was 
consulted  by  a  fine  appearing,   exceptionally  well 
nourished  man;  whose  circumstances  were  the  very 
best  that  could   be  desired,  in  regard  to  a  small 
abrasion  upon  the  glans  penis.    This  had  appeared 
a  day  or  two  after  a  suspicious  exposure,   and  had 
probably  resulted  from  friction  during  intercourse. 
I  told  this  gentleman  that  while  the  sore  had  noth- 
ing at  all  alarming  about  it,  yet  it  would  bear  close 
watching,  and  dismissed  him.      In  a  few  days — at 
the  end  of  two  weeks  from  the  date  of  exposure — 
the   sore  became  slightly   indurated,  constituting 
the  parchment  variety   of  chancrous  induration. 
This  chancre  disappeared  in  a  very  short  time,  but 
was  followed  by  a  most  malignant  course  of  syph- 
ilis.    True  tubercular  lesions  appeared  in  various 


Lydston.  109 

situations,  and  deep  ulcerations  developed  and  ran 
their  course  inside  of  three  months,  the  patient 
barely  escaping  with  his  life. 

We  can  never  judge  the  severity  of  the  syphil- 
itic infection,  by  the  character  of  the  primary  sore, 
and  this  case  serves  as  a  very  forcible  illustration 
of  this  statement.  In  private  practice  gentlemen, 
you  will  seldom  see  cases  of  this  sort,  and  only 
those  of  you,  who  in  the  future  are  so  fortunate  as 
to  enjoy  the  privileges  of  some  large  hospital, 
will  be  apt  to  realize  the  severity  of  syphilis  in  its 
more  marked  and  serious  phases. 

I  have  just  stated  that  it  is  impossible  to  predict 
the  severity  of  syphilis  by  the  character  of  the 
primary  sore,  but  this  statement  requires  some 
qualifications,  e.  g. ,  in  cases  of  phagedaenic  chan- 
cre we  can  prognose  a  severe  course  of  syphilis, 
not  because  of  any  intrinsic  severity  of  the  infec- 
tion, but  because  the  constitution  is  at  fault. 
This  constitutional  defect  will  have  the  same  influ- 
ence upon  the  general  symptoms,  that  it  does  upon 
the  primar}^  lesion  in  inducing  phagedaena.  The 
character  of  the  earlier  eruptions  will  influence  the 
prognosis,  for  the  milder  and  more  insignificant 
these  are,  the  milder  the  subsequent  course  of  the 
disease  is  apt  to  be,  and  vice  versa.  This  is  ex- 
emplified in  cases  of  malignant  syphilis,  in  which 
the  earlier  lesions  are  deep  and  destructive.     Ves- 


110  Lectures  on  Syphilis. 

iGular,  and  still  more,  pustular  eruptions,  indicate 
a  severer  type  of  the  disease  than  do  the  papular 
and  erythematous  lesions. 

Now  gentlemen,  I  have  given  you  all  that  I 
think  necessary  or  practical  regarding  the  path- 
ology and  course  of  syphilis.  Remember  its  phys- 
io-pathological features,  and  you  will  have  an  all 
powerful  advantage  over  those  physicians  whose 
ideas  of  syphilis  are  entirely  bounded  by  the  pro- 
position that  ''Pox  is  syphilis,  syphilis  is  pox, 
the  cause  is  venereal,  and  mercury  and  potash  are 
good  for  it.  "  Please  don't  look  at  the  disease  in 
that  way,  for  although  such  a  course  is  broad  and 
simple  enough,  it  is  the  pathway  to  imbecility  as 
far  as  the  scientific  study  and  treatment  of  syphilis 
are  concerned. 

I  will  conclude  this  morning,  by  depicting  in  a 
few  words,  a  typical  case  of  syphilis  :  A  young 
man  exposes  himself  by  a  suspicious  intercourse, 
and  during  the  performance  of  the  act,  causes  a 
little  abrasion  upon  the  glans  penis — or  possibly 
he  still  further  irritates  or  abrades  a  pre-existing 
abrasion  or  patch  of  herpes.  This  abrasion  may 
heal  in  a  day  or  two — or  may  escape  his  attention 
entirely  for  that  matter, — or  it  may  persist.  In 
about  two  or  three  weeks  a  little  hard  lump  or 
nodule  appears  on  the  site  of  the  abrasion.  This 
gradually  enlarges  until  of  the  size  perhaps   of  a 


Lydston.  Ill 

filbert.  In  a  few  days,  say  seven  or  eight,  small 
lines  of  hardness  appear  beneath  the  integument  of 
the  penis  leading  from  the  induration  and  in  a  few 
days  more,  small,  hard  and  freely  movable  lumps 
appear  in  the  groins.  What  have  we  here  ? 
Syphilitic  lymphitis  and  bubo.  Mark  how  the 
cells  are  slowly  traveling  on.  Now,  we  have  an 
interval  of  perhaps  six  weeks,  after  which  we  note 
an  enlargement  of  the  cubital  or  epitrochlear 
glands  at  the  elbow  over  the  internal  condyle, 
which  is  quite  characteristic,  and  enlargement  of 
the  general  system  of  lymphatics.  In  a  day  or  two 
or  more,  or  at  the  same  time,  we  have  an  eruption 
of  macules  or  papules  resembling  measles,  these 
being  scattered  over  the  surface  invariable  amount; 
— which  eruption  may  appear  simultaneously  with 
general  adenopathy  and  a  still  further  increase 
in  the  size  of  the  lymphatic  glands. 

A  sore  throat  may  now  be  complained  of.  After 
a  variable  interval  of  some  weeks  or  months,  we 
notice  an  eruption  of  papules,  most  prominent 
about  the  roots  of  the  hair  on  the  forehead — the 
venereal  crown, — which  papules  may  become  vesic- 
ular or  pustular,  according  to  the  intensity  of  the 
infection  and  the  constitutional  condition  of  the 
patient.  Sore  throat  is  frequently  experienced 
shortly  after  the  appearance  of  the  roseola,  or  more 
likely  during  the  papular  eruption,  and   syphilitic 


112  Lectures  on  Syphilis. 

iritis  is  likely  to  occur  at  any  time  after  the  appear- 
ance of  the  papules.  Late  in  the  disease  the  iritic 
inflammation  takes  on  the  so  called  ''gummy''  or 
nodular  form,  when  it  is  quite  characteristic,  but 
the  early  syphilitic  iritis  is  practically  indis- 
tinguishable from  the  rheumatic  form. 

During  the  latter  part  of  the  first  year,  bone 
pains  and  nodes  are  apt  to  appear,  l^ut  they  may 
appear  earlier.  Falling  of  the  hair  occurs  usually 
during  the  early  months  if  at  all,  and  in  common 
with  the  form  of  lesion  known  as  the  mucous 
patch,  is  most  likely  to  occur  during  the  papular 
eruption. 

Pustular  and  ulcerative  lesions  begin  to  appear 
during  the  latter  part  of  the  first  year  or  eighteen 
months,  and  are  succeeded  by  ecthyma,  rupia, 
tubercular  or  gummy  lesions  of  the  bones,  skin, 
brain  and  other  viscera,  and  various  nervous 
lesions,  with  destructive  bone  changes  and  other 
lesions  characteristic  of  the  "tertiary"  period  or 
period  of  sequelae.  These  latter  severe  lesions 
may  crop  out  from  time  to  time  during  the  life  of 
the  patient,  or  may  be  delayed  until  very  late  in 
life.  The  life  of  the  patient  may  eventually  be 
destroyed  by  profound  pathological  changes  in  the 
cerebro-spinal  axis,  or  abdominal  viscera. 

At  the  next  lecture  gentlemen,  we  will  consider 
the  treatment  of  syphilis. 


Lecture  VI. 

Treatment  of  Syphilis.— Simplicity  of  local  treatment  of  chancre.— 
Avoidance  of  caustics  and  ointments. — Excision  of  chancre. — Advan- 
tages of  excision.— Supposed  antidotal  effect  of  mercury  in  syph- 
ilis.— Proper  method  of  using.— Power  of  mercury  to  induce  fatty 
degeneration  and  elimination  of  morbid  material. — Uniformity  of  all 
successful  methods  of  treatment,  in  producing  fatty  degeneration. — 
Clevenger's  theory  of  the  mechanical  action  of  mercury. — Probabil- 
ity of  mercury  entering  the  system  in  both  mechanical  and  chemical 
conditions.— Action  of  mercury  upon  the  blood. — Action  varies 
widely  under  different  conditions. — Action  of  iodine  in  syphilis. — 
When  to  begin  the  use  of  mercury.— Form  of  mercurial  to  be  select- 
ed.—Importance  of  protracted  treatment.— Mercury  by  inunction 
and  fumigation.— Local  use  of  mercurials.— Mercury  by  hypodermic 
injection. 

Gentlemen: — We  now  come  to  that  portion  of 
our  course,  which  you  no  doubt  are  much  more 
anxious  to  learn  than  the  more  abstruse  and  to 
you  perhaps,  less  practical  topic  of  the  pathology 
of  syphilis.  Eemember  what  I  have  already  told 
you,  however,  regarding  the  necessity  for  a  good 
idea  of  the  pathology,  in  order  that  you  may  under- 
stand the  rationale  of  the  therapeutics  of  the 
disease. 

We  have  studied  the  treatment  of  the  primary 
sore  in  connection  with  the  description  of  its 
pathological  characters,  but  there  are  some  points 
which  will  bear  repetition,  and  others  to  which  I 
have  not  yet  alluded,  but  which  appear  to  me  very 
important.  In  the  first  place,  do  not  forget  that 
the  chancre  is  to  be  coaxed,  not  driven,  and  that  it 


114  Lectukes  on  Syphilis. 

will  cause  little  annoyance  if  you  give  it  half  a 
chance.  Use  the  black  or  yellow  wash,  calomel  or 
iodoform  powder,  or  even  simple  absorbent  cotton 
as  a  dressing,  and  let  the  induration  take  care  of 
itself.  If  you  wish  to  see  by  contrast,  the  results 
of  meddlesome  officiousness,  try  rubbing  a  hard 
chancre  with  nitrate  of  silver,  and  then  apply  some 
nasty,  greasy  ointment.  You  will  have  a  fine  mess 
of  it,  and  a  condition  of  afikirs  which  I  often  see 
in  patients  who  have  been  treated  in  this  manner, 
by  physicians,  drug  clerks,  or  very  often  by  them- 
selves. Avoid  grease  and  nitrate  of  silver,  as  an 
abomination,  if  you  would  not  lose  your  patients' 
confidence.  If,  as  in  the  case  of  a  mixed  sore,  it 
becomes  necessary  to  cauterize,  use  a  caustic,  and 
have  done  with  it.  and  not  an  irritant  like  nitrate 
of  silver,  which  sears  but  does  not  destroy.  Apply 
carbolic  acid  followed  by  the  fuming  nitric,  or  bet- 
ter still,  use  pure  bromine  or  the  actual  cautery. 
The  form  of  caustic  is  not  so  important  as  the  man- 
ner of  its  use:  Select  your  caustic  early  in  prac- 
tice, and  stick  to  it  until  you  know  how  to  use  it. 
As  a  last  injunction  instruct  your  patient  in  the 
matter  of  rest.  Let  him  rest  the  afi'ected  member 
by  avoidance  of  sexuality  in  thought  or  action,  by 
taking  very  little  exercise,  and  no  stimulants,  and 
lastly  by  handling  it  as  little  as  possible.      The 


Lydston.  115 

oftener  he  examines  himself  to  note  the  progress  of 
the  case,  the  worse  he  will  eventually  be. 

There  is  one  radical  method  of  dealing  with  the 
chancre,  which  I  commend  to  your  attention,  and 
which  is  often  a  wise  thing  to  do.  I  refer  to 
the  treatment  by  excision.  It  is  claimed  by  some 
advocates  of  this  method,  that  by  it  the  general 
symptoms  are  modified  and  in  some  instances  pre- 
vented entirely,  not  even  the  indolent  glandular 
changes  being  perceptible.  Theoretically,  if  the 
views  of  the  pathology  of  the  disease  which  I  have 
called  to  your  attention,  be  correct,  excision  of  the 
initial  induration  ought  to  prevent  general  infec- 
tion completely,  but  unfortunately  this  has  as  yet 
to  be  proven  to  be  the  case  in  actual  practice.  As 
for  myself,  I  am  performing  excision  whenever 
the  patient  will  consent,  and  am  trying  to  arrive  at 
a  definite  conclusion  in  regard  to  the  matter,  from 
actual  observation.  I  have  already  studied  ten 
cases  in  this  way,  and  have  become  pretty  thor- 
oughly convinced  that  the  operation  is  of  benefit. 
I  have  not  yet  omitted  the  administration  of  mer- 
cury, but  am  positive  that  excision  followed  by 
the  exhibition  of  the  drug  is  productive  of  better 
results  on  the  whole,  than  the  treatment  of  mer- 
cury alone.  There  are  several  considerations  which 
may  be  advanced  and  which  are  in  the  main  indor- 


116  Lectures  on  Syphilis, 

sed  by  Otis,  in  favor  of  the  operation,  in  which 
nearly  all  will  agree,  viz. :  We  thereby  remove  a 
constant  focus  of  infection,  which  is  present  as  long- 
as  the  induration  persists.  2d.  We  afonce  remove 
a  large  mass  of  syphilized  cells  which  would  other- 
wise only  be  removed  by  the  slower  process  of 
fatty  degeneration,  absorption  and  elimination.  3d. 
We  obviate  the  possibility  of  the  transmission  of 
the  disease  to  others  by  means  of  the  initial  lesion, 
a  point  of  great  importance  to  married  persons. 
4th.  We  lesson  the  danger  of  suppurating  bubo, 
in  case  the  chancre  should  inflame.  5th.  We  re- 
move a  constant  source  of  irritation,  and  lessen  the 
danger  of  phagedeena  and  inflammation  which 
might  disable  the  patient.  6th.  The  patient  is  able 
to  resume  his  marital  relations  at  once,  after  the 
incision  has  cicatrized  perfectly.  Why  it  is  that 
we  cannot  prevent  constitutional  syphilis,  by 
excision  of  the  chancre  prior  to  local  glandular 
changes,  is  not  clearly  explicable,  if  we  accept  the 
view  that  the  disease  is  practically  local  primaril}^ 
It  is  probable  that  a  morbid  impression  has  been 
made  upon  the  tissues  by  the  syphilitic  poison, 
which  began  the  moment  infection  occurred,  and 
which  has  extended  far  beyond  the  limits  of  the 
initial  lesion  before  its  appearance.  Excision  of 
the   chancre  should  be  preceded  by  washing  the 


Lydston.  117 

parts  in  a  solution  of  bichloride  of  mercury  1-1000. 
The  ulceration  if  any  exist,  should  then  be  cauter- 
ized, and  dusted  with  calomel.  The  chancre  should 
now  be  transfixed  with  a  tenaculum,  raised  from 
its  bed,  and  the  mass  of  induration  quickly 
removed  with  a  sharp  scalpel  or  curved  scissors. 
The  parts  should  be  sutured  with  fine  catgut  or 
silk,  and  the  parts  kept  at  rest  for  a  few  days  with 
cold  water  dressings.  Within  forty-eight  hours  as 
a  rule,  the  wound  will  have  united,  and  the 
stitches  may  be  removed.  In  a  few  days,  if  no 
lesion  be  present,  the  patient  may  resume  his  mar- 
ital relations. 

The  constitutional  treatment  of  syphilis,  is 
naturally  a  subject  of  paramount  importance. 
Errors,  more  serious  in  their  effects  than  the  dis- 
ease itself,  are  often  committed  by  those  whose 
practice  is  not  founded  upon  a  sound  pathological 
basis.  The  disease  has  long  been  treated  upon  the 
principle  that  there  is  present  a  constitutional 
poison,  which  must  be  antidoted,  and  mercury  has 
appeared  to  be  the  antidote.  Hutchinson  has 
taught  that  this  drug  has  the  property  of  neutral- 
izing the  specific  virus  upon  which  syphilis  is 
supposed  to  depend.  This  theory  of  the  antidotal 
eflfect  of  mercury,  has  been  accepted  by  some  of 
our    best    syphilographers.     They,    however,    in 


118  Lecttjkes  on  Syphilis. 

thus  accepting  the  antidotal  doctrine,  have  seemed 
to  consider  it  all-sufficient,  and  have  failed  to  ex- 
plain the  the  physiological  action  of  the  drug,  and 
have  given  it  solely  because  experience  has  proven 
that  it  is  curative  in  syphilis.  Now,  we  find  that 
even  when  the  system  has  been  completely  satur- 
ated with  mercury,  even  to  the  extent  of  producing 
severe  ptyalism,  the  disease  returns  directly  the 
drug  is  withdrawn,  thus  showing  that  the  syphilis 
has  in  no  sense  been  antidoted.  On  the  contrar}^, 
the  case  is  usually  worse  than  ever.  On  the  other 
hand^  we  find  that  the  slow^  continuous  and  moder- 
a^te  use  of  mercury^  for  a  period  corresponding  to 
the  maximum  time  of  the  normal  duration  of  the 
disease  as  nearly  as  ruay  he^  and  without  at  any 
time  producing  its  full  physiological  effects^  will 
hring  about  a  cure^  which  can  he  accomplished  in  no 
other  way. 

It  is  well  known  that  mercury  has  the  power  of 
inducing  fatty  degeneration,  and  elimination  of 
inflammatory  products,  or  in  oth^r  words,  ' '  of 
relieving  tissues  encumbered  with  superfluous  and 
obstructive  material.  "  This  condition  of  the 
tissues  is  precisely  what  we  have  in  syphilis,  and 
as  mercury  is  the  best  remedy  we  have  for  such  a 
pathological  state,  irrespective  of  causation,  we 
administer  it  throughout  the  natural  course  of  the 


Lydston.  119 

disease,  not  to  antidote  a  poison^  hut  to  remove  the 
iiiorbid  results  jproduced  hy  it^  as  fast  as  they  are 
formed^  until  finally  the  syphilitic  impression  upon 
the  organism  has  naturally  exhausted  itself.  We 
have  already  seen  that  the  "  virus  "  of  syphilis  is 
not  a  material  substance,  but  practically  consists 
in  an  influence  which  a  degraded  cell  has  over 
another  which  is  healthy,  causing  rapid  prolifer- 
ation and  obstructive  accumulation  of  the  cells  so 
influenced.  It  is  a  rather  peculiar  fact,  that  every 
method  of  treatment  for  syphilis  that  has  been 
advocated  for  the  last  two  or  three  centuries,  has 
comprised  such  measures  as  tend  to  produce  rapid 
tissue  change.  The  sweating  cure,  the  use  of  hot 
baths  as  at  the  Hot  Springs  of  Arkansas,  the  purga- 
tion and  starvation  cures,  Boeck's  method  of 
syphilization,  and  the  treatment  by  pustulation 
with  tartar  emetic,  all  of  which  have  been  recom- 
mended by  various  authorities  at  difierent  times, 
are  chiefly  active  through  their  power  of  inducing 
fatty  changes  in  the  tissues. 

The  action  of  mercury  upon  the  system  has 
been  the  subject  of  considerable  controversy, 
particularly  as  regards  the  form  in  which  it 
enters  the  blood.  A  very  ingenious  theory  was 
promulgated  a  few  years  ago  by  Prof.  S.  V. 
Clevenger,    of  Chicago.     The  professor  has    en- 


120  Lectukes  on  Syphilis. 

deavored  to  .show  that  mercury  does  not  enter 
the  system  as  a  chemical  compound,  but  as  me- 
tallic mercury  in  an  exceedingly  fine  state  of 
subdivision,  and  that  it  acts  upon  disease — particu- 
larly syphilis — in  a  purely  mechanical  manner,  by 
pushing  the  syphilized  cells  through  the  fine 
capillaries,  and  eventually  into  the  various  elimin- 
ative  areas  of  the  body,  from  which  they  are  re- 
moved as  is  other  excrementitious  matter. 

Clevenger  has  found  by  examination  of  the  tis- 
sues after  the  use  of  mercury  by  inunction,  that 
they  are  filled  with  minute  globules  of  the  metal, 
thus  showing  that  it  does,  in  that  instance  at  least, 
enter  the  blood  in  a  state  of  fine  subdivision. 
Another  argument  is  the  fact  that  free 
mercury  is  to  be  found  in  the  tissues  of 
patients  who  have  been  taking  the  drug  for 
sometime . 

-  The  prevailing  view  has  been,  that  mercury 
enters  the  system  as  a  chemical  compound,  and 
brings  about  an  antidotal  effect,  or  produces  a 
fatty  metamorphosis  of  the  diseased  cells. 

My  own  idea  is  that  mercury  may  enter  the 
blood  in  either  form.  When  it  enters  as  a  chem- 
ical compound ,  it  may  split  up  so  as  to  liberate 
a  certain  amount  of  the  pure  metal,  or  entering 
as   metallic    mercury,    it  may   undergo    chemical 


Lydston.  121 

changes  in  the  tissues,  these  effects  varying  in  dif- 
ferent cases.  Certain  it  is  that  finely  subdivided 
mercury  introduced  into  the  great  physiological 
chemical  laboratory  of  the  body,  is  quite  likely  to 
undero^o  chemical  chano^es.  Should  it  be  demon- 
strated  that  mercury  cannot  exist  in  the  body  as  a 
chemical  compound,  and  that  it  cannot  act  in  any 
but  a  mechanical  manner,  I  should  still  be  in- 
clined to  doubt  its  alleged  ferret-like  properties 
of  chasing  and  pushing  the  diseased  cells  out  of 
the  back  doors  and  chimneys  of  the  economy,  and 
should  be  inclined  to  believe  that  it  acted  by 
blocking  up  the  vessels  leading  to  the  syphilitic 
neoplasia,  and  thus  enhancing  their  own  intrinsic 
tendenc}^  to  fatty  degeneration.  Practically,  I  am 
firmly  convinced  that  the  drug  acts  by  inducing 
fatty  degeneration,  but  whether  by  a  mechanical 
or  chemical  action,  or  by  a  combination  of  both — 
which  is  highly  probable — does  not  seem  to  be  of 
any  great  moment. 

The  action  of  mercury  upon  the  blood  is  of 
great  practical  interest,  inasmuch  as  by  its  use 
two  diametrically  opposite  effects  may  be  pro- 
duced, according  to :  1st.  The  dose  used;  2d. 
The  duration  of  its  administration;  3d.  The  con- 
stitutional condition  of  the  patient;  and  4:th,  the 
stage  of  the  disease.  If  the  drug  be  given  in  full 
doses  for  a  few  days,  or   in   frequently  repeated 


122  Lectures  on  Syphilis. 

small  doses  for  twent3^-four  to  thirty-six  hours, 
severe  stomatitis  and  ptyalism  may  be  produced. 
If  it  be  given  in  a  less  vigorous  fashion  for  a  longer 
period,  we  may  have  pallor  and  debility,  due  to  a 
depreciation  in  the  quantity  and  quality  of  the  red 
blood  corpuscles,  to  defil)rination  of  the  blood 
plasma,  and  increased  tissue  waste.  A  certain 
degree  of  these  effects  is  necessary  in  the  treat- 
ment of  syphilis,  but  it  is  our  chief  aim  to  keep 
them  within  bounds,  and  to  avoid  the  danger  of 
producing  permanently  injurious  effects.  Such 
effects  as  great  pallor,  wasting,  and  debility,  pus- 
tular or  vesicular  eruptions  with  fever  known  as 
the  ''mercurial  fever,''  and  marked  tremors,  may 
result  from  the  action  of  mercury,  and  that  too, 
without  the  occurrence  of  ptyalism.  On  the  other 
hand,  small  doses  of  mercury,  in  various  cachectic 
or  anaemic  conditions,  particularly  during  the 
sequelae  of  syphilis,  will  rapidly  and  markedly 
increase  the  quantity,  and  improve  the  quality  of 
the  red  corpuscles  and  fibrine,  thus  lessening 
h^^draemia.  This  statement  is  based  upon  the 
experiments  of  Prof.  Keyes  with  the  ht^matome- 
ter,  and  moreover,  upon  personal  observation  of 
the  action  of  the  drug. 

There  is  another  remedy  which  ex^^erience  has 
shown  to  be  curative  in  syphilis,  and  which  is 
second  only  to  mercury.     I  refer  to  iodine,  which 


Lydston.  123 

in  the  form  of  the  iodides  is  exceedingly  useful, 
especially  in  late  syphilis.  The  iodides, — of  which 
potassic  iodide  is  the  type — act  in  two  ways  in  the 
cure  of  syphilis :  viz,  first,  by  their  own  intrinsic 
power  of  producing  fatty  degeneration,  and  elim- 
ination of  morbid  products,  and  second,  by  liberat- 
ing and  exciting  to  renewed  activity  the  mercury 
which  may  be  stored  up  in  the  tissues,  thus  assist- 
ing its  action.  It  is  evident  that  the  first  of  these 
effects  is  the  most  important,  for  the  iodides  have 
a  most  pow^erful  effect  in  resolving  the  products  of 
inflammatory  changes,  or  of  adventitious  deposits, 
irrespective  of  their  cause.  I  make  this  assertion 
in  the  face  of  the  argument  that  iodine  can  cure 
syphilis,  only  by  liberating  mercury  from  the 
tissues,  and  that  it  is  the  mercury  and  not  the 
iodides  that  produces  the  curative  effects.  That 
this  is  incorrect  is  shown  by  the  benefiicial  effects 
of  iodide  of  potassium  in  cases  of  late  syphilis  in 
which  mercury  has  never  been  administered.  * 

Having  decided  upon  the  administration  of  mer- 
cury in  the  constitutional  management  of  syphilis, 
when  shall  we  begin  its  use  ?  It  is  claimed  by  some, 
that  it  is  not  good  practice  to  begin  treatment 
until  the  secondary  symptoms  develop,  until,  in 
short,  the  case  is  matured,   as   mercury   will  have 

*  In  the  British  and  Foreign  Medical  Eeview  for  Oct.,  1845,  Hassing, 
of  Copenhagen,  reported  195  cases  of  syphilis,  70  of  which  were  cured 
by  the  iodide  of  potassium  alone,  without  mercury  at  any  stage. 


124  Lectures  on  Syphilis. 

little  effect  prior  to  that  time.  Now  I  believe  that  it 
is  our  duty  to  begin  treatment  just  as  soon  as  we  are 
positive  of  the  diagnosis,  as  we  thereby  shorten  the 
duration  of  the  initial  lesion,  and  modify  or  even 
prevent,  secondary  symptoms.  To  save  the 
patient  from  lesions  upon  the  body  or  face,  which 
"he  who  runs  may  read,"  is  very  desirable,  and 
is  only  to  be  accomplished  by  early  treatment.  It 
must  be  acknowledged  however,  that  those  cases 
in  which  treatment  is  not  begun  until  pronounced 
eruptions  appear,  sometimes  seem  to  respond  more 
readily  to  therapeutic  measures,  and  to  give  rather 
less  annoyance  during  the  active  period,  than  those 
in  which  mercury  is  given  as  soon  as  the  chancre 
develops.  Whether  the  prospect  of  a  permanent 
cure  is  brighter,  is  questionable. 

Having  determined  upon  the  administration  of 
mercury,  it  remains  to  select  an  eligible  prepara- 
tion. The  mildest  and  least  irritating  form  of  the 
drug,  is  the  protiodide,  or  as  it  is  sometimes 
termed,  the  green  iodide.  It  is  best  given  in 
pill  form,  in  doses  of  on  the  average,  one-fifth  of 
a  grain,  thrice  daily.  This  dose  is  to  be  continued 
for  several  days,  and  then  increased  one  pill  per 
day  until  the  gums  become  somewhat  tender,  or 
the  stomach  and  bowels  are  disturbed.  I  generally 
give  the  drug  until  the  gums  are  slightly  affected, 


Lydston.  135 

and  then  gradually  lessen  the  dose  until  the 
patient  is  taking  about  half  the  amount  necessary 
to  produce  slight  physiological  effects.  This,  as 
Dr.  Keyes  terms  it,  is  the  patient's  average  dose, 
and  is  usually  from  two  to  four  pills  of  the  strength 
mentioned,  daily.  It  is  generally  continued 
throughout  the  course  of  treatment.  It  is  well  to 
bear  in  mind  the  possibility  of  injurious  effects 
from  the  cumulative  action  of  the  drug,  and  also 
the  fact  that  it  is  apt  to  lose  its  effect  upon  the  dis- 
ease after  a  time.  A  good  plan  is  to  omit  the 
protiodide  at  intervals  of  two  or  three  months, 
and  give  potassic  iodide  pretty  freely  for  about  four 
weeks.  In  this  way  any  mercury  which  may  be 
stored  up  in  the  tissues,  is  liberated,  rendered 
active,  and  eliminated,  and  the  system  again 
rendered  susceptible  to  its  action  by  the  time  the 
pills  are  resumed.  By  proceeding  in  this  manner, 
you  will  always  avoid  the  possibility  of  injuring 
your  patient  with  mercury. 

It  is  always  a  matter  of  great  difficulty  to  induce 
our  patients  to  take  medicine  for  a  sufficient  length 
of  time  to  effect  a  cure.  They  are  prone  to  find 
fault  with  us  if  we  are  honest  with  them,  and  to 
suspect  us  of  sordid  motives  if  we  attempt  to 
coerce  them  into  prolonged  treatment.  It  is  a 
solemn  fact  gentlemen,  that  people  try  desperately 


126  Lectures  on  Syphilis. 

to  compel  the  physician  to  be  dishonest.  They 
mistake  honesty  for  lack  of  skill,  and  will  more 
readily  pay  the  quack  huge  fees  for  false  promises 
and  blatant  pretenses,  than  the  scientific  physician 
a  moderate  amount  for  skillful  treatment.  They 
have  always  at  their  tongue's  end  a  long  list  of 
their  friends  who  were  cured  of  a  bad  case  of  syph- 
ilis (?)  by  Dr.  So-and-So,  in  three  months.  In  spite 
of  this  perverseness  of  human  nature,  however,  it 
is  your  duty  to  tell  your  patient  that  if  he  wants 
to  get  well,  he  must  take  medicine  for  at  least  two 
years,  and  if  any  doubt  exists  at  the  end  of  that 
time  he  had  better  add  another  year,  especially  if 
he  has  matrimonial  intentions.  Allow  no  syphilitic 
patient  to  marry  under  three  years  from  the 
appearance  of  the  chancre,  if  you  would  have  clear 
consciences. 

Another  difficult  item  in  the  management  of 
most  cases  of  syphilis,  is  convincing  the  patient 
that  it  is  absolutely  necessary  for  him  to  avoid 
the  use  of  liquor  and  tobacco  for  an  extended 
period,  and  that  he  must  abstain  from  the  various 
dissipations  and  excesses  to  which  he  has  been 
accustomed.  This  point  must  be  insisted  upon 
however,  and  with  good  conduct  upon  the  part  of 
the  patient  assured,  half  the  battle  will  have  been 
gained. 


Lydston.  127 

In  some  cases  you  will  find  that  your  patient 
does  not  tolerate  mercury  well,  and  that  a  diarrhoea 
or  gastric  disturbance  follows  the  slightest  attempt 
to  crowd  the  drug.  In  this  event,  one-eighth 
grain  of  ext.  hyoscj^amus  should  be  added  to  each 
pill,  A  good  plan  too,  is  to  give  the  patient  a  few 
five  grain  powders  of  bismuth  subnitrate,  with 
instructions  to  take  one  whenever  the  stomach  or 
bowels  become  troublesome.  In  other  cases,  the 
patient  will  stand  a  large  amount  of  mercury,  and 
I  have  repeatedly  given  several  grains  of  the  pro- 
tiodide  daily  for  some  weeks,  without  affecting  the 
gums  or  the  digestive  tract  in  the  slightest 
degree.  In  such  cases  the  large  doses  should  be 
kept  up  for  a  few  weeks,  and  then  diminished  to 
about  four  or  five  pills  daily.  In  some  cases  you 
will  find  the  pil.  duo.  introduced  by  Dr.  Bum- 
stead  to  be  an  excellent  preparation,  especially 
when  the  patient  is  anaemic  and  debilitated.  The 
pil.  duo.  contains  gr.  ii.  of  pil.  hydrarg.  and  gr.  i. 
of  ferri  sulph.  exsiccat.  It  should  be  given  pre- 
cisely like  the  protiodide.  It  usually  produces 
constipation,  hence  an  occasional  dose  of  hunyadi 
or  bitter  water  may  be  necessary. 

When  a  patient  fails  to  respond  readily  to  the 
internal  administration  of  mercury,  or  when  gas- 
tro-intestinal  irritation  is  marked,  the  drug  may  be 


128  Lectures  on  Syphilis. 

used  by  inunction.  The  oleate  is  the  best  prepa- 
ration, although  too  expensive  for  some  patients. 
The  twenty  per  cent,  solution  should  be  used,  and 
about  3i  rubbed  into  the  axilla  morning  and 
night.  As  the  axilla  become  irritated,  the  rubbing 
may  be  done  at  the  flexures  of  the  joints,  where 
the  skin  is  thin  and  absorption  readily  occurs. 
The  mercurial  ointment,  though  less  elegant,  may 
be  used  as  a  substitute  for  the  oleate.  It  may  be 
rubbed  in,  or  spread  upon  a  white  flannel  band  in 
contact  with  the  abdomen,  the  band  being  shifted 
about  occasionally,  and  the  skin  kept  clean  by 
daily  washing.  Another  good  plan  in  hospital 
practice,  is  to  rub  the  ointment  upon  the  soles  of 
the  feet,  and  have  the  patient  wear  heavy  woolen 
socks. 

In  some  cases  inunctions  or  baths  must  be 
wholly  depended  upon,  and  it  may  be  said  in  this 
connection,  that  they  are  very  efficacious  in  obsti- 
nate skin  lesions.  Frictions  of  the  oleate  are  use- 
ful in  rupia,  and  will  also  assist  in  removing  the 
induration  of  the  primary  sore  unless  ulceration 
exists,  in  which  case  it  produces   irritation. 

A  simple  method  of  giving  a  mercurial  bath,  is  as 
follows  :  A  small  tin  plate  supported  by  a  tripod, 
an  alcohol  lamp,  and  a  pan  of  boiling  water,  are 
all  that  is  necessary.     The  patient  being  stripped, 


Lydston.  129 

seats  himself  in  a  cane  bottomed  chair,  and  wraps 
the  chair  and  his  body  thoroughly  in  blankets. 
About  twenty  grains  of  the  mercurous  chloride  is 
placed  upon  the  plate,  the  lamp  is  lighted,  and 
the  whole  apparatus  is  placed  under  the  chair.  In 
a  few  minutes  the  calomel  is  vaporized,  and  with 
the  steam  from  the  boiling  water,  is  deposited 
upon  the  skin  of  the  patient.  In  fifteen  minutes 
the  lamp  may  be  extinguished,  and  after  ten  min- 
utes more,  the  patient  should  wrap  himself  in  a 
dry  blanket  and  go  to  bed.  In  the  morning  he 
may  rub  himself  with  dry  towels,  the  mercury 
having  become  in  great  part  absorbed.  About 
three  baths  per  week  are  necessary.  Calomel  is 
the  best  preparation  for  fumigation,  because  of  its 
freedom  from  irritating  properties,  and  the  readi- 
ness with  which  it  volatilizes  without  reduction  to 
the  metallic  condition.  The  red  oxide  also  vola- 
tilizes readily,  but  its  fumes  are  more  irritating  to 
the  respiratory  tract. 

It  is  sometimes  necessary  to  bring  a  patient 
under  the  influence  of  mercury  very  rapidly,  e.  g., 
in  cases  of  syphilitic  iritis,  in  which  a  few  hours 
delay  might  be  fatal  to  the  integrity  of  the  eyes. 
In  such  an  event  calomel  in  doses  of  yV  S^-  every 
hour,  will  accomplish  the  desired  result;  and  if 
necessary,   ptyalism  can  be  produced  in  this  man- 


130  Lectukes  on  Syptlis. 

ner  within  twenty-four  to  forty-eight  hours. 
Another  method  of  rapid  and  efficacious  introduc- 
tion of  mercury,  is  by  Lewin's  method  of  hypo- 
dermic injection.^  From  yV  to  |^  of  a  grain  of  the 
bichloride,  in  combination  with  ^V  g^.  of  morphia 
and  a  small  quantity  of  sodium  chloride,  are  dis- 
solved in  fifteen  minims  of  distilled  water,  and 
injected  into  the  cellular  tissue,  preferably  of  the 
back,  once  or  twice  daily,  f  There  is  a  vast  differ- 
ence in  the  susceptibility  of  different  patients  to 
these  injections.  I  have  never  seen  an  abscess 
produced  by  them,  but  some  patients  complain 
bitterly  of  the  pain  following  their  administration. 
In  others,  hard  and  painful  indurations  follow  their 
use.  If  the  precaution  is  taken  however,  of  intro- 
ducing the  needle  well  into  the  cellular  tissue 
before  injecting  the  fluid,  very  little  trouble  will 
be  caused  in  the  majority  of  cases.  It  is  probably 
the  best  treatment  for  syphilis,  in  a  large  number 
of  cases,  if  you  can  get  your  patients  to  attend 
strictly  to  treatment.  As  an  adjunct  to  internal 
treatment,  the  injections  are  excellent,  and  I  am  at 
present  giving  them  in  most  of  my  cases.  There 
is  one  point  to  which  I  desire  to  call  attention,  viz: 
the  bichloride  makes  the  needle  very  brittle,  and 
unless  you  change  it  frequently,  you  are  quite  like- 

*Lewin,  "Behandlung  der  Syphilis,  mit  Subcutaner  Sublimat— 
injection,"  Berlin,  1869. 

tStern,  Progres  Medicale,  Paris,  1878. 


Lydston.  131 

ly  to  break  it  off  in  the  tissues,  an  accident  which 
the  patient  is  quite  liable  to  criticise.  For  the  aver- 
age patient  in  the  hands  of  the  general  practitioner, 
it  is  probable  that  Lewin's  method  is  inferior  to 
the  internal  use  of  the  mild  iodide. 

In  the  case  of  females  with  very  weak  stomachs, 
or  in  infantile  syphilis,  the  gray  powder  or  hy- 
drarg.  cum  creta,  is  an  excellent  mercurial  prepar- 
ation. If  you  have  to  crowd  the  mercurial,  do  so 
by  superadding  fumigations  or  inunctions,  rather 
than  by  increasing  the  internal  dose.  A  prepar- 
ation recently  extolled  abroad,  is  the  tannate  of 
mercury,  which  is  claimed  to  be  perfectly  un- 
irritating.  The  peptonate  is  another  fanciful 
preparation  used  by  our  French  confreres.  At  my 
next  lecture  gentlemen,  I  will  mention  the  evil 
effects  of  mercury. 


Lecture  YII. 

Necessity  for  appreciating  the  evil  effects  of  mercury  when  improp- 
erly given.— Prejudice  against  its  use.— Depression  from  mercury. — 
Mercurial  ptyalism  and  stomatitis.— Care  of  the  teeth  during  a 
mercurial  course,  to  prevent  ptyalism. -Causes  of  salivation.— 
Treatment  of  salivation  and  stomatitis. — Rheumatoid  pains  as  an 
indication  of  excessive  use  of  mercury. — Pain  in  the  heels  and  soles 
of  the  feet  from  mercury. — Possibility  of  some  of  the  alleged  late 
lesions  being  due  to  mercury. — Action  of  iodine  preparations. — 
Iodides  in  precocious  svphilis  —Methods  of  using  iodine  and  its 
preparations.— Large  doses  of  the  iodides  in  destructive  and  nervous 
lesions. — Unpleasant  and  injurious  effects  of  the  iodides  in  excessive 
doses. —lodism  and  its  treatment.— Iodine  eruptions.— Tendency  to 
the  use  of  questionable  preparations  in  syphilis. — Mistura  alterans, 
(Mc.  Dade's),  Tayuga,  Potassium  bichromate,  Coca,  Iodoform 
and  iron.— Local  management  of  certain  syphilitic  lesions.— Necro- 
sis of  bones  in  late  syphilis. 

Gentlemen: — There  is  a  strong  tendency  upon 
the  part  of  most  teachers  upon  the  subject  of  ther- 
apeutics, to  speak  only  of  the  good  effects  which 
are  claimed  to  result  from  the  administration  of 
various  drugs,  and  to  avoid  the  discussion  of 
those  evil  effects  which  are  likely  to  occur  at  the 
hands  of  the  inexperienced  or  careless  practitioner. 
This  I  believe  to  be  wrong,  and  I  will  therefore 
state  with  reference  to  mercury,  that  it  is  a  drug 
which  must  be  used  with  great  circumspection. 
You  will  meet  with  a  very  firm,  and  it  must  be 
confessed,  fairly  well  grounded  prejudice  against 
its  use,  existing  in  the  minds  of  the  laity.  We 
must  of  course,  take  into  consideration  the  fact 
that  many  of  the  alleged  evil  results  of  mercury 


134  Lectures  on  Syphilis. 

are  clae  to  the  fact  that  its  use  has  not  been  faith- 
fully persisted  in  for  a  sufficient  length  of  time, 
but  with  all  this,  there  is  undoubtedly  a  certain 
proportion  of  cases  in  which  serious  injury  to  the 
system  of  the  patient  may  be  justly  laid  at  the  door 
of  this  remedy.  With  proper  care,  however,  I  ven- 
ture to  assert  that  there  is  no  drug  Avhich  is  safer 
or  more  reliable,  and  I  have  yet  to  see  a  single 
case  of  permanent  injury  resulting  from  the  drug, 
when  properly  used. 

We  occasionally  meet  with  cases  in  Avhich  mer- 
cury has  a  very  unsalutary  effect  upon  the  patient, 
in  the  form  of  intense  mental  and  emotional 
depression,  even  when  very  moderate  doses  are 
given.  In  such  cases  it  may  be  necessary  to  give 
tonics  and  even  stimulants,  in  order  to  counteract 
this  condition.  Or  it  may  even  be  necessary  to 
stop  the  mercur}^  entirely,  and  depend  upon  potas- 
sium iodide.  Coca  will  be  found  useful  in  such 
cases. 

One  of  the  most  frequent  of  the  injurious 
effects  produced  by  mercury  is  ptyalism.  Saliva- 
tion in  any  marked  degree  is  always  injurious,  and 
^no  greater  effect  should  be  produced  than  a  slight 
redness  and  tenderness  of  the  gums,  with  a  slight 
increase  in  the  salivary  secretion,  a  coppery 
taste   in   the   mouth,  and   what   is   often  a    good 


Lydston.  135 

indication  to  diminish  the  amount  of  mercury,  a 
sensation  as  if  the  teeth  were  too  long.  To  this  lat- 
ter symptom  I  desire  to  call  especial  attention. 
Ulceration  of  the  cheeks  or  gums  sometimes  occurs 
without  previous  salivation,  but  this  is  quite  rare. 
To  prevent  these  annoyances,  the  mouth  and  teeth 
ought  to  be  thoroughly  put  in  order  by  the  dentist, 
prior  to  beginning  treatment.  Tartar  should  be 
removed  and  the  teeth  cleaned,  and  all  those  which 
are  decayed,  either  extracted  or  filled. 

The  causes  of  salivation  are,  iodiosyncrasy  with 
moderate  doses  of  mercury,  or  large  doses  without 
idiosyncrasy.  Diseases  of  the  mouth  and  gums 
predispose  to  it,  and  sometimes  exposure  to  cold 
and  wet  during  a  mercurial  course  will  bring  it 
on.  When  salivation  occurs,  it  requires  treatment. 
Of  course  the  first  thing  to  do  is  to  stop  the  mer- 
curial. The  chlorate  of  potassium  may  be  given 
internally,  and  a  mouth  wash  used,  composed 
of  the  chloride  of  potassium  and  tincture  of 
myrrh,  in  the  proportion  of  3i.  of  the  potass, 
chloride  and  ^i.  of  tr.  of  myrrh  to  §iv.  of 
water.  Glycerine  may  be  added  if  desired. 
Remember  to  specify  the  chloride,  and  not  the 
chlorate  in  this  mixture.  In  some  severe  cases  of 
salivation,  the  patient  cannot  swallow  solid  food, 
and  whether  this  be  the  case  or  not,  fluid  aliment 


136  Lectures  on  Syphilis. 

is  indiGated.  I  hope  that  you.  may  see  a  case  of 
mercurial  salivation  sometime,  in  the  practice  of 
somebody  else,  as  a  sort  of  warning  to  you  regard- 
ing the  abuse  of  a  really  excellent  drug.  The  fetor 
of  the  breath  in  these  cases  is  something  horrible, 
and  is  due  to  the  presence  of  decomposing  fat  in 
the  saliva,  produced  by  the  action  of  mercury  upon 
the  tissues  and  eliminated  by  the  salivary  glands. 
In  some  cases  of  mercurial  stomatitis,  the  cheeks, 
tongue  and  lips  are  fearfully  swollen,  perhaps 
ulcerated,  and  covered  with  a  yellowish  pultaceous 
deposit,  which  is  eminently  characteristic. 

You  will  find  in  certain  instances  chronic  pains 
of  a  rheumatic  character,  muscular  and  articular, 
resulting  from  mercury,  and  I  have  learned  by 
experience,  that  when  a  patient  who  is  taking  much 
mercury,  begins  to  complain  of  vague  pains  in  the 
forearms  and  legs,  it  is  time  to  drop  mercury,  and 
give  iodine.  There  is  one  peculiar  fact  which  I 
must  mention,  and  that  is,  that  some  patients  com- 
plain bitterly  of  pain  in  the  heels,  and  sometimes 
the  soles  of  the  feet,  similar  to  that  which  occurs 
in  gonorrhceal  rheumatism.  This  I  firmly  believe 
to  be  due  to  mercury.  When  your  patient  com- 
plains of  his  feet  being  tender,  lessen  the  amount 
of  mercury,  and  give  the  iodides,  if  you  would 
save  yourself  trouble .     There  is  a  serious  question 


Lydston.  137 

in  my  mind  whether  some  of  the  ulcerations  of  the 
mouth  and  tongue  in  the  later  periods  of  syphilis, 
may  not  be  due  to  mercury.  I  s«e  many  such 
cases  in  which  the  continued  use  of  the  drug  ap- 
pears to  make  matters  worse,  and  I  find  that 
when  iodides  at-e  substituted,  improvement  at  once 
occurs.  This  might  be  attributed  to  the  action  of 
the  iodine  in  liberating  and  revivifying,  so  to  speak, 
the  latent  mercury,  but  I  doubt  it  being  the  cor- 
rect explanation. 

The  use  of  the  iodides  in  syphilis  requires  some 
special  notice.  The  active  element  in  the  iodides, 
is  supposed  to  be  the  free  iodine  which  is  liberated 
in  the  system,  but  there  seems  to  be  some  differ- 
ence in  the  degree  of  effect  exerted  by  the  various 
salts.  The  potassic  iodide  is  the  most  powerful, 
but  is  the  most  liable  to  produce  gastro-intestinal 
irritation.  This  does  not  however,  impair  its  use- 
fulness to  a  great  extent,  for  it  is  the  most  gener- 
ally used  of  all  the  preparations  of  iodine.  The 
sodic  salt  is  milder,  and  is  a  useful  substitute  for 
the  potassic  iodide,  where  the  patient  has  a  feeble 
or  irritable  digestive  apparatus.  The  iodides  are 
often  and  successfully  used  in  combination,  the 
ammonium  iodide  being  combined  with  the  iodides 
of  potassium  and  sodium.  Pure  iodine  is  useful, 
but  often  too  irritating. 


138  Lectures  on  Syphilis. 

It  is  the  custom  with  most  practitioners,  to  use 
iodine    and    its    preparations    only    in    the    late 
periods   of  the    disease,    and    chiefly   in  tertiary 
lesions,  but  it .  will  be  found  that  many  cases  of 
obstinate   secondary  lesions   will  not  yield   until 
the  iodides  are  given.     As  I  have  already  stated, 
it  is  well  to  give  a  few  weeks'  course  of  the  iodides 
from  time   to    time,    throughout    the    course    of 
mercurial  treatment.     A  small  amount  of  the  bin- 
iodide  may  be  given  at  the  same  time  if  thought 
best.     In  cases  of  precocious  syphilis,    in  which 
destructive  lesions   or  nervous  changes  come  on 
early  in  the  disease,  the  iodides  are  our  chief  reli- 
ance.     It  is   in  late   syphilis   however,    that  the 
iodides  will  be  found  most  reliable,  especially  if 
combined  with  mercury  in  the  form  of  ' '  mixed 
treatment."      Gummy  lesions  require  an  excess  of 
the  iodides,  but  in  all  cases,  after    the  serious  les- 
ions are  under  control,  a  prolonged  mild  mercurial 
course  should  be  instituted.      This  is  the  proper 
method  of  treating  the  deeper  lesions  of  the  brain, 
spinal  cord,  bones,  viscera,  testicle,   etc.,   the   tub- 
ercular lesions  of  various  kinds,  the  various  scaly 
eruptions,  and  those  later  syphilides  which  tend  to 
aggregate  themselves  in  groups,  or  to  become  par- 
ticularly obstinate.     As  an  example  of  the  formu- 
lae for  the  mixed  treatment,  I  will  give  you  a  quite 
popular  combination: 


Lydston.  139 

R     Hydrarg-.  bichloridi gr.  iv 

Ammon.    iodidi 3  iii 

Kalii  iodidi 3  vji 

Tr.  cinclioiige   Co.    or   Syr.   Sarsap.    Co ^  viii 

•jj^   Sig_ — ^  ii  in  wineglassful  of  water  after  each  me'^I. 

Prof.  Gunn's  "three-eights"  mixture  is  an 
excellent  one  for  the  administration  of  iodine.  It 
is  as  follows: 

R    lodinii  Hesubl gr.  viii 

Potass,  iodidi 3  ^ii 

Syr.  Sarsap.  Co ^  viii 

M.  Sig. — S  i  dose. 

Always  instruct  your  patients  to  dilute  these 
preparations  well  before  taking,  as  they  are  all 
more  or  less  irritating  to  the  stomach,  and  as  far  as 
possible,  to  take  them  after  meals.  In  some  in- 
stances however,  in  which  the  patient's  digestive 
organs  are  not  very  sensitive,  the  iodides  may  be 
taken  with  advantage  while  fasting,  especially  if 
combined  with  a  vegetable  bitter,  like  quassia  or 
cinchona.  In  the  formula  which  I  have  given  you 
for  the  mixed  treatment,  you  are  likely  to  criticise 
the  combination  of  incompatibles  and  the  admin- 
istration of  the  irritating  bichloride,  but  if  you 
reflect,  you  will  see  that  the  ingredients  are  ration- 
ally compatible,  although  not  chemically  so.  We 
have  a  chemical  reaction  in  the  mixture,  which 
results  in  the  formation  of  the  biniodide,  which  is 
very  active  by  virtue   of  its  being  in  the  nascent 


140  Lectures  on  Syphilis. 

condition.  When  it  is  necessary  to  push  the  dose 
of  the  iodides,  do  so  by  adding  a  saturated  solution 
of  sodic  or  potassic  iodide,  to  be  taken  in  doses  of 
five  drops  thrice  daily  to  begin  with,  and  to  be 
subsequentl}^  increased  one  drop  daily  at  each  dose, 
until  the  limit  of  tolerance  has  been  reached,  or 
until  the  symptoms  yield,  when  the  dose  may  be 
reduced,  the  favorable  result  meanwhile  continu- 
ing. It  is  sometimes  necessary  to  use  mercurial 
inunctions  in  addition  to  the  iodides,  and  the  local 
application  of  the  oleate  sometimes  assists  in  the 
cure  of  the  lesions  amazingly. 

The  deep-seated  ulcerations, — especially  those  of 
the  throat, — syphilis  of  the  bones,  and  syphilis  of 
the  brain  and  cord,  often  require  enormous  doses 
of  the  iodides  before  they  exhibit  any  signs  of 
yielding.  In  the  venereal  wards  of  the  New  York 
Charity  Hospital,  a  daily  dose  of  two  or  three 
hundred  grains  of  potassic  iodide  was  nothing  un- 
usual, and  Van  Buren  relates  a  case  in  which  nine 
hundred  grains  were  given  daily  for  eleven  days. 
In  my  own  service  we  had  several  cases  in  which 
the  drug  was  increased  to  a  daily  allowance  of  four 
hundred  grains.  I  must  acknowledge,  however, 
that  I  was  never  fully  satisfied  as  to  the  purity  of 
our  hospital  drugs,  and  Yan  Buren  himself  told  me 
that  he  did  not  believe  it  possible  for  a  patient  to 


Lydston.  141 

tolerate  the  amount  of  iodide  which  we  so  common- 
ly gave  at  the  hospital,  if  the  drug  were  pure.  It 
would  seem  that  a  pair  of  kidneys  would  be  rather 
worthless,  after  eleven  days  work  at  the  daily  elim- 
ination of  two  ounces  of  the  iodide.  Making  due 
allowance  for  adulterations  however,  the  doses 
which  some  patients  will  tolerate,  are  amazing.  I 
have  one  patient  who  has  taken  three  hundred 
grains  daily  for  nearly  three  weeks,  and  I  am  cer- 
tain that  the  drug  is  perfectly  pure.  On  the 
other  hand  we  meet  cases  which  will  not  tolerate 
even  small  doses  of  the  iodides. 

Like  the  unpleasant  effects  of  mercury,  those  of 
iodine  require  more  than  casual  attention.  In  the 
first  place,  the  iodides  may  cause  sudden  and 
severe  ptyalism  in  patients  who  have  been  taking 
mercury  freely,  simply  by  suddenly  liberating  and 
rendering  active  the  latter  drug.  On  this  account, 
caution  should  be  exercised  in  the  use  of  the 
iodides  in  such  cases  as  have  been  under  a  pro- 
longed course  of  mercurials.  You  will  find  in 
every  case,  that  the  iodine  has  a  special  action 
upon  the  salivary  glands,  whether  the  patient  has 
been  taking  mercury  or  not.  If  you  will  take  a 
ten  grain  dose  of  the  iodide  of  potassium,  you  will 
find  that  you  can  taste  the  iodine  most  distinctly 
in  a  very  short  time,  and  that  your  saliva,  and  the 


143  Lectures  on  Syphilis. 

mucus  from  your  nasal  passages,  will  exhibit  a 
decidedly  yellowish  tinge.  The  nasal  mucus 
especially,  will  be  greatly  increased  in  amount. 

The  most  important  of  the  evils  which  may  be 
caused  by  the  iodides  is  the  condition  known  as 
"  iodism,  "  This  consists  in  a  feeling  of  depres- 
sion and  malaise,  nervous  irritability,  tinnitus 
aurium,  neuralgic  or  rheumatic  pains  in  various 
situations,  especially  in  the  bones  and  muscles,  and 
irritation  of  the  various  mucous  surfaces,  especial- 
ly those  of  the  eyes  and  nose.  The  latter  symptom 
may  be  merely  a  mild  coryza  or  may  amount  to 
a  very  severe  inflammatory  oedema  of  the  conjunc- 
tiva, nasal  and  lachrymal  apparatuses.  Severe 
diarrhoea  and  vomiting,  with  severe  griping  pain, 
may  occur  from  the  irritant  action  of  the  drug, 
and  may  necessitate  its  complete  suspension  for  a 
time.  Often,  however,  the  treatment  may  be  con- 
tinued by  substituting  the  sodium  for  the  potas- 
sium salt,  limiting  the  diet  to  rice  and  milk,  and 
giving  large  doses  of  the  subnitrate  of  bismuth. 
When  given  as  I  have  already  suggested,  by  begin- 
ning with  small  doses  and  gradually  increasing 
until  the  limit  of  tolerance  is  reached,  there  is 
usually  little  difficulty  in  administering  large  doses 
of  the  iodides. 

Eruptions  of  the  skin  are  liable  to  occur  from 
the  iodides,   and  some  patients  appear  to  have  an 


Lydston.  143 

idiosyncrasy"  which  renders  them  peculiarly  liable 
to  the  occurrence  of  eruptive  phenomena,  even 
when  quite  small  doses  are  given.  I  have  a  patient 
at  the  present  time  who  cannot  take  the  iodide  in 
ten  grain  doses  for  a  day,  without  the  development 
of  red  painful  swellings  upon  his  limbs.  In  the 
same  way  we  find  patients  who  are  liable  to  extreme 
iodism,  from  very  small  doses.  A  professional 
gentlemen  of  my  acquaintance  cannot  tolerate  the 
drug  in  doses  of  two  or  three  grains  without  the 
development   of  a   severe   coryza  in  a  few  hours. 

There  are  three  principal  forms  of  eruption  which 
may  result  from  iodine  and  the  iodides,  viz:  acne, 
erythema,  and  purpura.  Of  these  eruptions,  acne 
is  the  most  frequent,  and  may  be  slight  or  quite 
extensive,  the  pustules  varying  from  the  size  of 
the  head  of  a  pin,  to  quite  extensive  phlegmonoid 
abscesses.  Erythema  when  it  occurs,  is  usually 
situated  upon  the  nose,  cheeks,  or  forehead,  and  is 
followed  by  branny  desquamation.  It  may  how- 
ever, run  into  eczema.  Any  of  these  forms  of  erup- 
tion may  be  attended  by  considerable  heat  and 
itching. 

Severe  and  well-marked  purpura  hemorrhagica, 
is  occasionally  noted  in  cases  of  tertiary  syphilis 
treated  by  large  doses  of  the  iodide  of  potassium. 
In   such   cases   we  have   the   combined   evil  pro- 


144  Lectures  on  Syphilis. 

pensities  of  the  syphilitic  cachexia,  and  large 
doses  of  iodine,  to  explain  the  profound  blood 
changes  to  which  the  purpuric  extravasations  are 
attributable. 

All  of  the  evil  effects  of  the  iodides,  rapidly 
disappear  upon  the  cessation  of  the  drug,  and  the 
administration  of  such  tonics  as  quinine,  iron, 
and  cod  liver  oil,  with  free  doses  of  such  diuretics 
as  the  citrate  or  acetate  of  potassium.  The  cause 
of  the  evil  phenomena  described,  is  usually  defec- 
tive action  of  the  kidneys,  hence  the  advisability 
of  promoting  free  diuresis  during  a  course  of  the 
iodides.  Acne,  in  certain  special  cases  of  idio- 
syncrasy, may  be  prevented  by  the  administra- 
tion of  Fowler's  solution  of  arsenic,  conjointly 
with  the  iodides. 

There  is  a  great  tendency  on  the  part  of  the  pro- 
fession, to  recommend  various  new  and  questiona- 
ble preparations  in  the  treatment  of  syphilis.  Cer- 
tain vegetable  preparations  have  enjoj^ed  a  more 
or  less  long-lived  popularity  in  this  respect.  Sar- 
saparilla  was  long  thought  to  be  a  specific.  Among 
the  new  preparations  are  cascara  amarga,  berberis 
aquafolium,  stillingia  and  other  drugs,  alone  or  in 
combination.  I  advise  you  to  try  these  things,  in 
the  firm  belief  that  you  will  soon  discover  their 
fallacies,  and  come  back  to   our    reliable   friends. 


Lydston.  145 

iodine  and  mercury.  As  bitter  tonics  they  are  all 
more  or  less  useful,  but  as  specifics  they  are  arrant 
humbugs.  A  certain  quasi  patent  medicine,  known 
as  "Mc. Dade's  mixture,"  and  composed  of  various 
vegetable  ingredients,  was  introduced  a  short  time 
ago,  and  I  am  sorry  to  say,  was  fathered  by  no 
less  a  man  than  Marion  Sims,  and  indorsed  by 
some  other  very  good  men,  who  must  feel  proud 
of  the  distinction  of  having  attached  their  testi- 
monials to  a  remedy  which  is  now  heralded  in 
every  newspaper,  as  the  popular  remedy  for  syph- 
ilis. As  a  matter  of  fact,  it  is  on  a  par  with  its 
quite  as  respectable  contemporary,  the  three  S's, 
as  a  therapeutic  agent.  Tayuga  is  another  remedy 
of  doubtful  origin  which  was  recommended  some 
years  ago,  and  which  Dr.  J.  Nevins  Hyde,  of  this 
city,  gave  a  fair  trial  in  syphilis,  with,  he  claims, 
negative  results.  The  bichromate  of  potassium 
has  been  recently  recommended,  but  I  have  had 
no  experience  with  it.  It  is  best  to  be  liberal,  and 
give  different  remedies  a  fair  trial,  irrespective  of 
their  origin,  and  such  has  been  my  custom,  but  I 
think  that  you  will  find  that  the  proportion  of  cases 
of  syphilis  which  is  curable  by  the  judicious  use  of 
mercury  and  iodine,  is  so  large,  and  so  gratifying, 
that  you  will  waste  no  unnecessary  time  upon  new 
and  strange  drugs. "^     In  conclusion  I  will  mention 

*  Bumstead  and  Taylor  estimate  the  proportion  of  cures  at  about 
95  per  cent.,  but  this  is  somewhat  exaggerated. 


146  Lectukes  on  Syphilis. 

two  remedies  which  are  decidedly  beneficial  as  a 
tonic  in  syphilis,  viz.,  the  fl.  extract  of  coca, 
and  iodoform.  Coca  is  an  excellent  tonic  when 
used  conjointly  with  strictly  anti-syphilitic  treat- 
ment, and  tends  decidedly  to  relieve  the  nervous 
depression  from  which  most  syphilitics  suffer. 
Iodoform  Avill  be  found  most  useful  in  cases  which 
do  not  tolerate  mercury  and  iodine  well,  and  should 
be  combined  with  the  exsiccated  sulphate  of  iron 
or  the  iron  by  hydrogen,  the  latter  perhaps  being 
the  most  useful  and  convenient. 

Before  leaving  the  subject  of  the  treatment  of 
syphilis,  I  desire  to  call  your  particular  attention 
to  several  little  items  in  the  local  management  of 
the  disease,  which  may  prove  of  great  service  to 
you.  There  is  nothing  of  importance  to  add  to 
what  I  have  already  said,  regarding  the  treatment 
of  the  chancre  itself,  but  some  of  the  secondary 
lesions  require  attention.  Mucous  patches  some- 
times gives  great  annoyance,  and  refuse  to  yield  to 
purely  constitutional  treatment,  becoming  sluggish 
and  indolent.  In  such  an  event,  the  pure  acid  ni- 
trate of  mercury  will  be  found  to  be  the  best  appli- 
cation. Before  applying  it,  the  lesion  should  be 
dried  with  a  piece  of  l:)ibulous  paper  or  absorbent 
cotton.  The  surface  should  then  be  thoroughly 
cauterized,  after  which  it  is  again  dried.      The  ni- 


Lydston.  147 

trate  of  silver  may  be  used  in  the  same  manner. 
Sometimes  cauterization  is  not  tolerated,  the  sore 
becoming  inflamed  and  irritable.  In  such  cases 
the  tr.  benzoin  co.  will  be  found  most  efiectual. 
It  coats  the  lesion  with  a  deposit  of  the  gum  ben- 
zoin, and  in  addition  to  its  mildly  stimulant 
and  antiseptic  action,  protects  the  surface  from 
irritation.  When  mucous  patches  hypertrophy, 
and  form  tubercles  or  condylomata,  an  application 
of  hydrarg.  bichlor.  in  collodion  in  a  strength  of 
four  to  twenty  grains  to  the  ounce,  will  be  found 
to  remove  them  very  rapidly.  Calomel,  zinc 
oxide,  salicylic  acid  and  iodoform  are  also  all  quite 
useful  applications.  Washing  the  parts  in  salt  and 
water  followed  by  the  application  of  calomel  is 
also  of  service,  as  nascent  bichloride  is  formed 
and  acts  very  powerfully  upon  the  lesions.  In  case 
of  secondary  or  even  tertiary  lesions  upon  the  face 
which  are  non-ulcerative,  the  solution  of  bichlo- 
ride in  collodion  will  be  found  to  remove  them 
quite  rapidly.  Be  careful  however,  not  to  cause 
severe  blistering  of  the  skin  by  too  powerful  or 
too  frequent  applications.  In  case  of  ecthymatous 
or  rupial  ulcerations,  frictions  with  the  oleate  are 
beneficial.  Gummy  ulceration,  especially  when 
situated  in  the  mouth  or  pharynx,  will  be  best 
treated  by  the  application  of  benzoin.     Although 


148  Lectures  on  Syphilis. 

iodoform  is  also  quite  effectual,  it  is  far  more  un- 
pleasant, for  most  people  do  not  like  to  have  such 
an  odorous  application,  in  so  close  proximity  to 
their  nasal  and  digestive  organs. 

We  sometimes  meet  with  cases  of  necrosis  of 
the  bones  in  various  situations  in  late  syphilis,  or 
more  properly  speaking,  the  period  of  sequelae. 
Try  and  determine  whether  the  osseous  troubles 
are  due  to  syphilis  or  to  mercury,  and  then  treat 
them  upon  general  principles.  Remember  that 
tonics  are  always  indicated  in  these  cases,  and  that 
the  iodides  are  our  main  reliance,  mercury  if  giv- 
en at  all,  being  indicated  only  in  tonic  doses.  As 
a  parting  injunction  in  the  treatment  of  syphilis,  I 
wish  you  to  remember  that  cleanliness  is  nowhere 
productive  of  better  results  than  in  this  disease. 
The  Turkish  or  Russian  bath  once  or  twice  weekly, 
has  an  excellent  general  as  well  as  local  effect, 
and  where  possible,  recommend  them  to  all  your 
patients. 


Lecture  VIII. 

Congenital  Syphilis.— Acquired  syphilis  of  children,— Methods  of 
acquiring  the  disease.— Methods  of  contracting  the  disease  by 
hereditary  transmision.— Necessity  of  caution  in  differentiating  the 
acquired  and  congenital  forms  of  syphilis  ia  children. — Intra-uter- 
ine  syphilis. — Syphilitic  abortion.— Treatment  of  syphilitic  abor- 
tion.— Occasional  masquerading  of  congenital  syphilis  as  "  scrof^ 
ulosis."— Peculiar  appearauce  of  the  hereditarily  syphilitic  child.— 
Congenital  syphilitic  lesions  of  the  skin  and  mucous  membranes, 
nails,  hair,  bones,  and  viscera.— Apoplectic  effusions.— Sudden 
death  of  syphilitic  children.  —  Hydrocephalus  from  congenital 
syphilis.— Predisposition  to  tuberculosis.— Hutchinson's  descrip- 
tion of  the  teeth  in  hereditary  syphilis.— The  syphilitic  counten- 
ance.— Prognosis  and  treatment  of  congenital  syphilis." 

Gentlemen:  I  have  thought  it  advisable  before 
leaving  the  subject  of  syphilis,  to  devote  an  hour 
to  the  discussion  of  the  congenital  form  of  the 
disease.  I  believe  that  this  is  a  topic  of  practical 
iniportance,  and  one  which  although  not  entirely 
neglected  by  the  more  systematic  works  upon 
syphilis,  has  not  often  been  presented  in  a  practical 
manner.  I  have  used  the  term  congenital  syphilis, 
in  preference  to  "infantile  syphilis,"  for  the  reason 
that  children  may  acquire  syphilis  in  a  number  of 
ways  independently  of  hereditary  transmission. 
When  thus  acquired,  ihe  cours.e  and  various  phe- 
nomena of  syphilis  are  in  no  wise  different  from 
the  same  affection  in  the  adult.  A  child  may 
become  inoculated  with  syphilis  by  kissing  persons 
with   oral   or  labial   syphilides,    such   as   mucous 


150  Lectures  on  Syphilis. 

patches,  fissures  and  ulcers,  or  it  may  acquire  it 
from  nursing  its  syphilitic  mother  or  nurse. 
The  possibility  of  acquiring  the  disease  by  yacci- 
nation  must  also  be  remembered,  although  at  the 
present  day,  when  non-humanized  virus  is  almost 
exclusively  used,  such  an  accident  can  only  occur 
through  the  most  gross  and  culpable  carelessness. 

There  is  also  the  possibility  of  contamination 
through  attempts  at  sexual  congress,  by  both  male 
and  female  examples  of  depravity.  I  have  myself 
seen  two  cases  of  syphilis  in  children,  acquired  in 
this  manner.  These  instances  have,  however,  no 
bearing  upon  congenital  syphilis,  excepting  that 
great  care  is  to  be  exercised  in  difierentiating  the 
two.  An  error  here,  might  seriously  compromise 
an  innocent  person  on  the  one  hand,  or  allow  a 
guilty  one  to  escape  upon  the  other. 

In  the  case  of  alleged  vaccinal  syphilis,  care 
should  be  taken,  else  an  innocent  operator  may  be 
held  responsible  for  the  sins  of  the  child's  parents. 
Remember  gentlemen^  that  a  diagnosis  is  difficult 
without  a  hnowledge  of  the  natural  course  of  syph- 
ilis^ and  that  a  more  or  less  typical  course  of  syph- 
ilitic phenomena^  following  a  pre-existing  chancre^ 
is  the  only  positive  proof  of  acquired  syphilis^  he 
the  subject  old  or  young. 

The  methods  of  acquiring  syphilis  by  heredity, 
we  have  already   studied  to   some  extent.     It    is 


Lydston.  151 

probable  that  either  parent  may  transmit  syphilis 
to  the  child,  although  as  far  as  the  father  is  con- 
cerned, the  question  of  his  power  to  procreate  a 
syphilitic  child,  without  first  infecting  the  mother, 
is  still  sub-judice.  Otis  claims  that  the  presence 
of  the  syphilitic  cell,  is  incompatible  with  life  in 
the  spermatozoa,  but  it  would  be  necessary  to 
demonstrate  the  cell  as  an  entity,  before  it  could 
be  admitted  as  a  necessity  in  this  particular 
method  of  transmission.  The  probable  truth  is, 
that  while  the  presence  of  the  syphilitic  germinal 
cell  is  necessary  in  order  that  the  semen  should  be 
inoculable,  its  presence  is  unnecessary  in  order 
that  the  father  should  infect  the  foetus.  This 
results  from  the  fact  that  the  spermatozoa  of  a  man 
who  is  in  the  flower  of  syphilis,  have  been  so  modi- 
fied that  they  are  incapable  in  some  instances  of 
generating  a  healthy  child.  The  child  need  not 
necessarily  be  afiected  by  the  ordinary  phenomena 
of  syphilis,  but  may  present  certain  perversions  of 
growth  and  nutrition,  which  are  not  ordinarily  con- 
sidered to  be  syphilitic.  That  syphilis  may  so 
impress  the  spermatozoa,  that  the  child  may  be 
cachectic  and  ill  nourished,  if  not  actually  syphil- 
itic, is  probably  true.  It  is  almost  beyond  doubt, 
that  the  syphilitic  impress  is  liable  to  masquerade  as 
rickets  or  scrofulosis  in  the  child.     Independently 


152  Lectures  on  Syphilis. 

of  theoretical  reasoning,  it  is  a  positive  fact  that 
the  children  of  apparently  healthy  mothers,  by 
syphilitic  fathers,  are  often  affected  by  certain  con- 
ditions of  mal-nutrition  which  are  singularly  bene- 
fitted by  anti-syphilitic  treatment,  and  which  are 
probably  "attenuated  syphilis."  That  the  mothers 
are  not  reall}^  syphilitic,  is  of  course  an  open  ques- 
tion, but  in  a  large  proportion  of  cases,  the  evi- 
dence is  in  their  favor. 

It  is  an  undisputable  fact,  that  when  the  mother 
is  syphilitic,  the  offspring  rarely  escapes.  Her 
power  of  transmitting  the  disease  lasts  much  longer 
than  that  of  the  father,  as  may  be  readily  explained, 
if  we  stop  to  consider  the  intimate  anatomical  and 
physiological  relations  which  exist  between  the 
foetus  in  utero  and  its  mother.  The  exception  of 
the  mother  who  becomes  pregnant  while  healthy, 
and  does  not  become  infected  with  syphilis  until 
the  seventh  month,  is  to  be  borne  in  mind  in  con- 
sidering the  probability  of  the  mother  infecting  her 
child. "^  It  has  been  demonstrated  that  the  female 
may  procreate  syphilitic  children,  long  after  she 
has  lost  the  power  of  infecting  a  healthy  man. 

As  a  matter  of  practical  importance  it  had  best 
be  remembered,  that  while  it  remains  to  be  positive- 
ly shown,  that  either  parent  may  infect  the  child 
independently  of  the  other,  cases  have  occurrred 

*Did.ay,  "  De  la  Syphilis  des  Nonveaux-nes." 


Lydston.  153 

which  seem  to  prove  its  truth,  and  until  the  ques- 
tion is  absolutely  settled,  it  is  best  to  be  cautious, 
and  remain  upon  the  safe  side. 

The  changes  in  the  foetus  which  result  from  the 
syphilitic  infection  or  impression,  are  of  vital  im- 
portance, and  often  decide  the  question  as  to  the 
birth  of  a  living  syphilitic  child.  The  ovum  may 
be  blighted  early  in  the  course  of  utero-gestation 
and  be  cast  off,  or  absorbed,  or  it  may  develop  to  a 
greater  or  less  extent,  according  to  the  severity 
with  which  the  syphilitic  infection  manifests  itself. 
The  disease  may  manifest  itself  in  several  ways, 
and  sometimes  in  a  rather  obscure  fashion.  A 
general  shriveling  or  dwarfing  of  the  structure  of 
the  foetus  may  occur,  with  resulting  death,  and  a 
consequent  abortion.  Serious  visceral  lesions 
sometimes  occur,  and  destroy  life,  e.  g.,  I  recall  a 
case  in  which  a  woman  miscarried  and  was  de- 
livered of  a  still-born  child,  whose  liver  was  so 
enormously  hypertrophied  as  to  cause  serious 
difficulty  in  delivery.  Intra-uterine  hydrocephalus 
is  an  occasional  result  of  syphilis,  and  I  once  saw 
Dr.  Munde  perform  craniotomy  upon  a  case  of 
this  kind,  in  the  New  York  Maternity  Hospital. 

Disease  and  malformation  of  the  osseous  system 
are  frequent  results  of  syphilis,  and  it  is  my  own 
conviction   that  many  congenital   deformities  de- 


IQ^  Lectubes  on  Syphilis. 

pend  upon  imperfect  development,  resulting  from 
intra-uterine  syphilis.  These  however,  are  the 
more  obscure  manifestations  of  the  disease. 

Apoplectic  effusions  often  occur  in  the  syphilitic 
foetus,  and  if  all  aborted  syphilitic  children  were 
examined  critically,  much  light  might  be  shed 
upon  the  effects  of  syphilis  upon  the  vascular  sys- 
tem. 

Well  marked  eruptions  are  apt  to  occur  upon 
the  foetus  in  utero,  and  most  syphilitic  foetuses  will 
present  some  unmistakable  external  lesion. 

It  is  exceptional  that  a  woman  in  full  syphilis, 
succeeds  in  carrying  a  child  to   term,    even  when 
under  quite  active  treatment.      Abortion  usually 
occurs,  and  is  perhaps  most  often  due  to  death  of 
the    foe,tus,    which  then  acts  as    a  foreign    body, 
and  is  cast  off.     It  is  not  unusual  however,  for  the 
abortion  to  occur  as  a  result  of  placental  changes. 
Placentitis  hemorrhagica,  fatty  and  waxy  changes 
in  the  placenta,  all  interfere  with  its  uterine  attach- 
ments primarily,  and  secondarily  affect  the  vital- 
ity of  the  foetus  by  interfering  with  the  interchange 
of  nutritive  material,  necessary  for  its   sustenance. 
Placental  apoplexy   is  especially  apt  to  bring  on 
abortion,  particularly  when  the  blood  extravasates 
upon  its  attached  surface.     When  the  hemorrhage 
is  parenchymatous,  abortion    is   not  so  hkely  to 
occur. 


Lydston.  155 

Syphilis  is  one  of  the  most  potent  causes  of 
abortion,  and  when  a  female,  however  healthy, 
aborts  frequently,  a  suspicion  of  syphilitic  taint  is 
justifiable. 

The  treatment  of  syphilitic  abortion  is  of  neces- 
sity the  administration  of  mild  mercurials  through- 
out the  course  of  pregnancy.  It  hy  no  means  fol- 
lows^ that  hecause  a  woman  aborts  as  a  result 
of  syphilis^  she  must  necessarily  give  hirth  to  a 
syphilitic  child ^  hence  it  is  always  just  and  consci- 
entious to  try  to  carry  the  pregnancy  to  full  term. 
The  better  the  apparent  health  of  the  mother,  and 
the  later  the  period  of  the  disease,  the  more  emi- 
nently proper  such  a  course  becomes. 

When  a  syphilitic  child  goes  on  to  full  term, 
which  often  occurs,  it  may  be  born  apparently 
healthy  and  well  nourished,  but  as  a  rule  it  devel- 
ops symptoms  of  inherited  syphilis  within  a  few 
weeks.  In  the  majority  of  instances,  syphilis  de- 
velops before  the  child  is  three  months  old.  In 
some  cases  however,  some  years  elapse  before 
symptoms  develop,  and  then  they  are  more  or  less 
marked.  Cases  have  been  related  in  which  lesions 
of  the  pharynx,  viscera  and  bones  occurred  in 
adult  life  for  the  first  time,  the  childhood  of  the 
patient  having  been  apparently  healthy.  It  is 
probable    moreover,  that   a   generation    may    be 


156  Lectures  on  Syphilis. 

skipped  before  the  syphilitic  impression  manifests 

itself. 

As  has  been  already  asserted,  many  of  the  cases 
of  disturbed  nutrition  termed  struma  or  scrofulo- 
sis,  are  probably  syphilitic.  Hutchinson  and  Ast- 
ley  Cooper,  both  tacitly  admitted  this  in  their  day, 
and  Cooper's  favorite  remedy  for  scrofula,  consist- 
ed of  bichloride  of  mercury  in  Huxham's  tincture 
of  cinchona  bark. 

In  the  majority  of  instances,  a  syphilitic  child  is 
indelibly  stamped  with  the  hereditary  impress. 
It  is  as  a  rule,  remarkable  for  its  pinched,  shrivelled 
appearance,  due  probably  to  a  lack  of  fatty  tissue 
from  malnutrition.  The  new  born  baby  has  the 
look  of  an  old  man,  and  if  it  lives  long  enough,  it 
has  often  the  most  supernatural  look  of  intelli- 
gence that  could  well  be  imagined.  This  wise 
little  old  man  is  as  remorseless  as  fate,  in  divulging 
the  sins  of  his  parents.  He  says  little,  but  ex- 
presses much,  and  he  is  a  burden  greater  than  the 
"Old  Man  of  the  Sea"  as  long  as  he  lives. 

If  not  present  at  birth,  lesions  of  various  kinds 
develop  from  time  to  time.  I  have  seen  a  child 
born  with  a  well  marked  roseola.  Chaps  and  ex- 
coriations of  the  quasi-mucous  surfaces  about  the 
genitals,  anus  and  mouth,  are  apt  to  develop,  and 
may  form  true  plaques  muqueuse  or  even   condy- 


Lydston.  157 

lomata.  A  scalded  appearance  of  the  anus,  is  quite 
characteristic.  Snuffles  develop  after  a  time,  and 
the  nares  become  so  clogged  up,  that  respiration  and 
nursing  are  interfered  with,  and  nutrition  still 
farther  impaired.  This  ozoena  may  lead  to  necrosis 
of  the  nasal  cartilages. 

A  livid  macular  eruption  is  sometimes  seen,  and 
ulcerations  may  form  about  the  mucous  orifices. 
Papular  and  pustular  lesions  are  not  infrequent, 
and  quite  characteristically  afiect  the  palms  and 
soles  in  certain  instances.  Subcutaneous  tuber- 
cular lesions  may  be  seen  in  some  few  cases. 

A  very  peculiar  eruption  is  sometimes  seen  in 
syphilitic  children,  which  is  quite  identical  in  its 
physical  characteristics  with  ordinary  pemphigus 
in  the  adult.  This  "infantile  pemphigus"  is  an 
unmistakable  evidence  of  syphilis.  It  consists  of 
an  eruption  of  bullae  or  blebs,  sparsely  distributed 
over  the  skin.  Sometimes  but  one  or  two  bullae 
are  present.  It  is  especially  apt  to  afiect  the  palms 
of  the  hands  and  soles  of  the  feet.  The  blebs  are 
filled  with  fluid  which  varies  in  its  physical  char- 
acters from  slightly  turbid  serum  to  pus.  When 
the  cuticle  yields,  the  fluid  dries  into  a  greenish 
crust,  and  ulceration  occurs  beneath,  precisely  as 
in  syphilitic  ecthyma  or  rupia. 

It  has  been  claimed  that  infantile  pemphigus 
may  result  from  simple  cachexia,    but  this  is  not 


l^Q  Lectures  on  Syphilis. 

probable,  and  it  may  generally  be  accepted  as  an 
evidence  of  syphilis.  When  a  syphilitic  child 
develops  pemphigus,  a  bad  type  of  disease  is  evi- 
denced, and  the  case  is  usually  hopeless. 

Another  almost  pathognomonic  indication  of 
syphilis,  may  occur  in  the  form  of  keratitis.  This 
is  often  attributed  to  scrofula. 

The  epithelial  appendages  of  the  body,-  such  as 
the  hair  and  nails,  are  not  so  likely  to  become 
affected  in  congenital  syphilis  as  in  the  adult,  but 
a  brittle,  lustreless  condition  of  the  nails  is  occa- 
sionally noted.  As  Hutchinson  has  shown,  the 
nails  may  be  repeatedly  shed,  or  they  may  split 
and  become  ragged  in  appearance.  They  may 
even  become  affected  by  suppuration  of  the  matrix, 
or  onychia.^ 

It  has  been  generally  accepted  that  the  osseous 
lesions  of  children  are  insignificant  as  compared 
with  the  same  changes  in  the  adult  syphilitic. 
This  is  however  a  mistake,  and  in  my  own  exper- 
ience I  have  been  able  to  observe  a  considerable 
number  of  bone  lesions  in  children.  In  fact,  one 
of  the  most  frequent  lesions  observed  in  the  cases 
of  congenital  syphilis  at  the  N.  Y.  Charity  Hos- 
pital was  syphilitic  inflammation  of  the  bones.  It 
was  the  exception  rather  than  the  rule,  that  serious 
visceral  lesions  were  unaccompanied   by  osseous 

*HutGliinsoii.    "Patholog.  trans."  XII.    259. 


Ltdston.  159 

troubles.  Taylor  has  called  especial  attention  to 
the  lesions  of  the  bones  in  congenital  syphilis.* 
This  eminent  authority  has  shown  that  the  most 
frequent  seat  of  the  osseous  lesions  is  at  the 
diaphyso-epiphyseal  junction  of  the  long  bones, 
certain  bones  however,  being  affected  with  especial 
frequency.  This  is  explained  by  the  fact  that  the 
processes  of  growth  and  nutrition,  are  most  active 
at  the  junction  of  the  diaphysis  and  epiphysis  of  a 
bone  in  any  situation. 

Most  frequently  the  bone  is  more  or  less  uni- 
formly enlarged,  although  in  certain  instances  the 
periosteum  seems  chiefly  affected.  Suppuration  is 
infrequent,  but  is  described  by  Bouchut  as  a  result 
of  softening  of  the  cartilages  of  the  epiphysis,  f 
Necrosis  is  not  very  frequent. 

The  most  important  of  all  the  manifestations  of 
hereditary  syphilis  are  the  lesions  of  the  viscera. 
The  processes  of  growth  and  nutrition  in  the  in- 
fant are  very  active,  and  constructive  changes  are 
especially  favored.  These  circumstances  are  par- 
ticularly conducive  to  the  proliferation  of  young 
connective  tissue,  in  the  parenchyma  of  the  viscera. 
When  present,  these  interstitial  proliferations 
are  usually  diffuse,  circumscribed  gummy 
changes  being  exceptional.      Such  cases  however, 

*  R.  W.  Taylor,  "Bone  Syphilis  in  Children." 

t  Bouchut.    "Maladies  des  Enfans  Nouveaux-nes,"  1861. 


160  Lectures  on  Syphilis. 

are  related.  Any  or  all  of  the  viscera  may  be  in- 
volved, the  connective  tissue  changes  being  espec- 
ially apt  to  affect  the  liver,  spleen  and  kidneys. 

There    is    in   syphilitic    new-born    children,    a 
marked  tendency  to  apoplectic  effusions  in  various 
situations,    particularly    in    the   meninges   of  the 
brain,  and  probably  also  the  cord.      The  condition 
known  as  cephal-h^ematoma  is  most  apt  to  occur  in 
syphilitic  children,  in  whom  the  vessels  seem  to  be 
characterized  by  great  tenuity.     If  the  labor  be  at 
all  difficult,  or  if  forceps  be  used,    there  is   great 
danger  of  intra-cranial  or  sub-peri  cranial  effusions. 
I  have  noted  three  cases  of  meningeal  hemorrhage 
in  new  born  syphilitic  children,  and  four  cases  of 
cephal-hsematoma,   three  of  which   were  undoubt- 
edly syphilitic.      In  one  case  the  child  developed 
a   cephal-hsematoma   soon   after  birth,  which    ab- 
sorbed in  a  few  weeks.     During  the  fourth  week 
the   child   developed  convulsions   and  died.      On 
autopsy  extensive  changes  in  all  the  viscera  were 
noted,  and  upon  the  surface  of  the  brain,  a  large 
clot  from  a  ruptured  meningeal  vessel  was  found. 
In   one   of  the   cases   of   meningeal    hemorrhage 
which  I  have  seen,  the  child  was  found  dead  by  its 
mother's  side,   and  a  suspicion   of  foul  play  was 
entertained.      The   autopsy   however,  showed  an 
extensive  meningeal  hemorrhaofe. 


Lydston.  161 

Cases  of  sudden  death  in  syphilitic  children,  have 
been  occasionally  noted  by  other  observers,  but 
there  seems  to  have  been  no  autopsy  in  the  majority 
of  instances,  at  least  no  explanation  for  these  cases 
has  been  given,  as  far  as  I  am  aware.  It  is  prob- 
able that  some  of  them  have  been  due  to  menin- 
geal hemorrhage. 

Children  are  apt  to  develop  hydrocephalus,  as  a 
result  of  syphilitic  inheritance.  I  recall  to  mind 
a  family  in  which  two  children  died  of  this  disease, 
as  a  result  of  congenital  syphilis.  The  so-called 
rachitic  appearance  of  the  skull  is  often  a  manifes- 
tation of  syphilis. 

It  is  probable  that  congenital  syphilis,  has  a 
more  or  less  marked  influence  in  the  causation  of 
tubercular  meningitis.  It  may  not  give  positive 
evidence  of  its  presence  by  a  development  of  une- 
quivocal syphilitic  disease,  and  yet  may  so  impair 
nutrition  as  to  develop  a  deposit  of  tubercle.  The 
syphilitic  soil,  is  one  in  which  the  tubercular  pro- 
cess will  flourish. 

The  most  accurate  description  of  the  symptoms 
of  hereditary  syphilis  that  has  ever  been  given,  is 
that  of  Mr.  Jonathan  Hutchinson.  The  syphilitic 
countenance  as  described  by  him  is  quite  charac- 
teristic, and  his  description  of  the  teeth,  in  heredi- 
tary syphilis,  is  classical.     The  evidences  given  by 


162  Lectures  on  Syphilis, 

the  teeth  are  not  pathogQomonic,  nor  are  they  al- 
ways present,  even  when  positive  signs  of  syphilis 
exist,  but  in  general  they  are  very  valuable. 

The  permanent  teeth,  instead  of  being  regular, 
and  symmetrically  developed,  are  irregular, 
notched  and  pegged  in  appearance,  and  the  confor- 
mation of  the  alveolar  arch  is  imperfect.  The  two 
upper  central  incisors  are  the  ' '  test  teeth. "  They 
are  short,  vertically  notched,  narrow  and  rounded 
at  their  corners. 

"Next  in  value  to  the  malformation  of  the  teeth," 
says  Hutchinson,  "are  the  state  of  the  patient's 
skin,  the  formation  of  his  nose,  and  the  contour  of 
his  forehead;  the  skin  is  almost  always  thick, 
pasty,  and  opaque  It  also  shows  pits  and  scars, 
the  relics  of  former  eruptions,  and  at  the  angles  of 
the  mouth  are  radiating  linear  scars,  running  out 
into  the  cheeks.  The  bridge  of  the  nose  is  almost 
always  low,  and  broader  than  usual,  often  it  is 
remarkably  sunken  and  expanded.  The  forehead 
is  usually  large  and  protuberant  in  the  region  of 
the  frontal  eminences;  often  there  is  a  well  marked 
broad  depression  a  little  above  the  eyebrows.  The 
hair  is  usually  dry  and  thin,  and  now  and  then  the 
nails  are  broken  and  splitting  into  laj^ers."  Inter- 
stitial keratitis  is  pathognomonic  of  inherited 
taint,  and  when  co-incident  with  the  syphilitic 
type  of  teeth,  the  diagnosis  is  beyond  a  doubt. 


Lydston.  163 

The  prognosis  of  congenital  syphilis,  is  of  course 
very  unfavorable.  The  earlier  the  eruptions  or 
other  symptoms  appear,  the  greater  the  danger. 
Marked  eruptions  occurring  shortly  after  birth, 
indicate  a  fatal  prognosis.  Severe  and  early 
ozoena,  in  badly  nourished  children,  is  of  like  im- 
port. Marked  visceral  lesions  and  apoplectic 
effusions,  are  always  fatal.  Lesions  of  the  bones,  if 
unaccompanied  by  marked  visceral  changes,  are 
not  so  unfavorable.  In  cases  of  enteritis  syphilitica, 
a  lesion  described  by  Lancereaux,  there  is  no  hope 
of  saving  the  child. 

In  the  face  of  the  unfavorable  prognosis  of 
hereditary  syphilis,  it  is  some  consolation  to  know 
that  as  a  rule,  a  syphilitic  child  is  better  dead,  for 
it  is  a  constant  danger  to  its  friends,  and  its  life  is 
at  best  but  a  miserable  one.  Sometimes,  however, 
a  syphilitic  child  becomes  fat  and  healthy,  under 
proper  treatment. 

The  treatment  of  congenital  syphilis,  is  to  be 
carried  out  in  two  ways,  viz. :  by  direct  medication, 
and  indirectly,  through  the  system  of  the  mother. 

The  best  internal  remedy  for  the  child,  is  the 
hydrarg.  cum  creta  or  gray  powder.  This  may 
be  given  in  doses  of  from  one,  to  three  or  four 
grains  three  times  daily.  In  very  young  children, 
inunctions  of  the  ung.  hydrarg.  or  hydrarg.  oleatis 


164  Lectures  on  Syphilis, 

must  be  depended  upon.  A  good  plan  is  to  spread 
a  piece  of  blue  ointment  the  size  of  a  large  filbert, 
upon  the  flannel  binder  once  daily.  The  delicate 
skin  of  the  child  absorbs  this  quite  readily.  Daily 
cleansing  with  soap  and  water,  and  frequent  shift- 
ing of  the  position  of  the  band,  are  necessary  to 
avoid  irritation.  The  soles  of  the  feet,  axillae,  and 
flexures  of  the  joints,  are  also  eligible  situations 
for  inunctions. 

In  older  children,  the  bichloride  of  mercury  may 
be  given  in  small  doses,  in  combination  with  some 
vegetable  bitter,  like  Huxham's  tincture.  Parvules 
of  the  hydrarg.cum  cretse,  protiodide,  or  mild  chlor- 
ide are  also  useful. 

The  general  condition  is  always  to  be .  borne  in 
mind  in  treating  congenital  syphilis,  and  cod  liver 
oil  and  iron  will  always  be  of  benefit.  The  syrup 
of  the  iodide  of  iron  is  the  best  preparation. 
Young  children  absorb  cod  liver  oil  readily,  when 
given  by  inunction.  The  oleate  of  mercury  may 
be  combined  with  the  oil.  Good  and  sufficient  nour- 
ishment is  always  required,  but  the  child  should 
not  nurse  from  its  mother,  unless  it  is  positive  that 
she  not  only  has,  or  has  had  syphilis,  but  is  in  fair 
general  health.  A  syphilitic  child  should  never  be 
reared  by  a  healthy  nurse,  that  is,  one  who  has  not 
had  syphilis.     In  general,  good  cow's  milk  is  the 


Lydston.  165 

best  for  the  child.  I  will  say  something  with  refer- 
ence to  the  nursing  of  syphilitic  children,  in  the 
next  lecture. 

When  the  child  is  nursed  by  its  mother  or  by  a 
nurse,  it  may  be  treated  through  the  medium  of 
the  breast  milk,  by  the  iodide  of  potassium.  This 
drug  is  eliminated  in  great  part  by  the  mammary 
glands,  and  this  physiological  fact  is  therefore  of 
therapeutical  service  in  hereditary  syphilis.  From 
five  to  ten  grains  may  be  given  four  or  five  times 
daily,  care  being  exercised  in  regard  to  the  pro- 
duction of  gastro-enteric  irritation  in  both  mother 
and  child. 

The  local  management  of  congenital  syphilis  is 
often  of  importance.  Perfect  cleanliness  is  a  par- 
amount indication.  Ulcers  and  excoriations  should 
be  kept  clean  and  dry,  and  dusted  with  calomel  or 
oxide  of  zinc.  Condylomata  are  to  be  treated  as 
in  the  adult.  Ozsena  requires  local  treatment,  and 
a  nasal  douche  of  some  antiseptic  solution  is  use- 
ful. The  preparation  known  as  Listerine  is  useful 
for  this  purpose.  It  should  be  diluted  with  about 
three  or  four  parts  of  water,  and  used  three  times 
daily.  Be  careful  not  to  use  harsh  applications  in 
syphilitic  lesions  of  children,  as  their  delicate  skins 
are  very  intolerant  of  such  measures. 


Lecture  IX. 

The  nursing  of  syphilitic  children.— Possibility  of  a  healthy  child  being 
born  of  syphilitic  mother,  and  of  a  syphilitic  child  being  born  of  ap- 
parently healthy  mother  —Attenuation  of  virus  by  passing  through 
the  system  of  foetus. — Belief  of  Hutchinson  in  the  primary  infection 
of  the  foetus.— Analogy  of  syphilization  of  foetus  to  inoculation  with 
virus  ot  variola.  Escape  of  the  child  from  infection  after  7th  month 
of  pregnancy.— Individual  insusceptibility  to  infection  — Analogy  of 
syphilization  to  vaccination.— Danger  of  infection  of  child  by  syphil- 
itic mother,  and  vice  versa. — A  desirability  of  artificial  feeding. 

Gentlemen  :  In  accordance  with  a  promise 
which  I  made  you  some  time  ago,  I  desire  to 
say  a  few  words  this  morning  regarding  the  nurs- 
ing of  syphilitic  children,  a  subject  of  quite  prac- 
tical interest  and  importance. 

The  question  of  the  management  of  infants  who 
are  the  subjects  of  hereditary  syphilis,  or  who  are 
the  children  of  syphilitic  mothers,  and  in  whom 
the  disease  is  likely  to  develop,  has  received  com- 
paratively little  attention  at  the  hands  of  syphil- 
ographers,  Fournier  having  perhaps  given  the  sub- 
ject more  attention  than  the  majority  of  observers. 
The  conclusions  to  which  his  studies  in  this  direc- 
tion have  led  him,  are,  first,  that  the  child  of  a 
syphilitic  mother  should  be  given  to  her  to  nurse, 
even  if  it  present  no  evidences  of  syphilis,  as  it  will 
almost  inevitably  exhibit  the  disease,  and  would 
run  the  risk  of  infecting  a    non-syphilitic    nurse. 


168  Lectures  on  Syphilis. 

Second,  that  if  the  child  be  syphilitic  and  the 
mother  apparently  healthy,  it  should  still  be  nursed 
by  her,  as  there  is  no  danger  of  maternal  infection 
by  the  infant.  The  consideration  of  the  manage- 
ment of  the  infant,  in  case  both  mother  and  child 
have  apparently  escaped,  but  the  father  is  in  the 
active  stage  of  syphilis,  is  passed  by  with  the  asser- 
tion that  there  is  absolutely  no  danger  to  either 
mother  or  child,  if  maternal  nursing  be  allowed. 
The  question  of  nursing  an  infant  born  free  trom 
syphilis,  although  its  mother  has  the  disease,  and 
it  having  escaped  as  the  result  of  a  mercurial 
course  administered  to  the  woman  during  gesta- 
tion, is  not  dwelt  upon. 

It  is  a  practical  fact  that  in  the  cases  ot  children 
who  have  inherited  syphilis,  but  in  which  the 
mother  has  apparently  escaped  the  disease,  no 
clearly  defined  instances  have  been  reported  of  the 
infection  of  the  mother  by  the  infant,  and  this  fact 
affords  the  foundation  for  "  Colles  law,"  so  called, 
viz.,  that  a  child  born  syphilitic  will  not  infect  the 
mother.  The  reverse  is  also  held  to  be  true,  viz., 
that  a  syphilitic  mother  is  in  no  danger  of  infect- 
ing her  child,  it  being  apparently  healthy,  unless 
her  disease  has  been  contracted  subsequent  to  de- 
livery, in  which  case  she  is  ultra-contagious  to  it. 
This    has  been  variously    explained.     One    very 


Lydston,  169 

plausible  argument  is  that  the  mother  already  has, 
or  has  had  syphilis,  contracted  either  before,  or 
during  the  pregnancy  in  question. 

This  would  imply,  that  it  is  impossible  for  a 
syphilitic  child  to  be  born  of  a  healthy  mother,  or  in 
other  words  that  it  is  absolutely  impossible  for  the 
father  to  transmit  syphilis  to  his  child,  without  the 
mother  being  secondarily  infected.  Others  deny 
the  possibility  of  the  child  inheriting  the  syphilitic 
taint  from  the  father,  excepting  secondarily, 
through  the  medium  of  the  mother. 

If  these  views  be  correct,  then  the  disease  must 
exist  in  the  mother  when  she  appears  to  remain 
healthy,  in  an  exceedingly  mild  form;  so  mild  in 
fact,  that  its  manifestations  escape  observation,  or 
it  must  remain  latent  for  a  longer  or  shorter  time, 
and  finally  manifest  itself  by  some  of  the  lesions 
characteristic  of  the  late  period  of  syphilis.  This 
might  result  from  the  fact  that  the  disease  expends 
its  violence  upon  the  child  in  utero,  thus  rendering 
the  infection  of  the  mother  comparatively  mild,  or 
the  secondary  period  of  the  disease  might  be  repre- 
sented and  replaced  by  the  manifestations  which 
occur  in  the  foetus,  thus  exempting  the  mother 
from  affections  of  a  secondary  character,  but 
rendering  her  none  the  less  liable  to  the  tertiary 
forms.     In  the  first  instance,    the  changes  in  the 


170  Lectures  on  Syphilis. 

foetus,  could  be  said  to  produce  an  attenuation  of 
the.  specific  principle,  just  as  the  virus  of  other  in- 
fectious diseases  may  become  attenuated  by  succes- 
sive inoculations. 

Hutchinson  believes  the  explanation  to  be  in  the 
manner  of  the  introduction  of  the  ''  virus"  into  the 
maternal  system,  using  as  an  analogy,  the  result 
of  inoculation  with  the  virus  of  variola,  which  pro- 
duces a  comparatively  mild  form  of  the  disease, 
while  inhalation  of  the  same  materies  morbi, 
causes  variola  of  the  severest  type.  This  implies 
that  the  syphilitic  poison  is  modified  in  some 
peculiar  manner  by  its  passage  through  the  foetal 
circulation.^  Fournier  is  undecided  upon  this 
point,  and  does  not  advance  any  very  definite 
views,  but  unites  with  the  majority  of  authorities, 
in  advocating  the  indiscriminate  nursing  of  the 
hereditarily  syphilitic  infant,  by  the  mother, 
whether  she  herself  appears  to  sufi:er  from  the 
disease  or  not.  • 

None  of  the  authorities  quoted,  state  that  it  is 
absolutely  impossible  for  the  mother  to  be  infected 
by  the  infant  in  such  cases,  but  they  simply  ad- 
vance the  clinical  fact  that  such  infection  has  not 
occurred.  Facts  have  been  recorded  by  many 
observers,    to   show   that  it  is  possible    for    the 

*Thus  it  is  assumed  by  Hutchinson,  that  the  foetus  may  be  infected 
with  active  syphilis  primarily,  and  without  the  intervention  of  the 
maternal  circulation.    This  is  a  mooted  point. 


Lydston.  171 

mother  to  contract  syphilis  during  pregnancy, 
without  necessarily  transmitting  the  disease  to  the 
child,  this  being  especially  true  in  case  of  her  in- 
fection after  the  seventh  month,  in  which  instance, 
according  to  Diday,  the  child  always  escapes.  This 
would  appear  to  be  a  powerful  argument  against 
the  mother  nursing  the  infant,  as  long  as  it  presents 
no  manifestations  of  the  disease,  although  she  her- 
self is  affected  by  it,  the  lesions  having  shown 
themselves  either  shortly  before,  or  immediately 
subsequent  to  delivery.  The  cases  in  which  the 
infant  escapes  the  disease,  when  it  has  existed  in 
the  mother  for  any  length  of  time  before  delivery, 
must  be  exceedingly  rare.  Fournier  thinks  that 
he  has  seen  a  certain  number.  The  instance  may 
however  occur,  especially  if  the  mother  be  brought 
under  the  influence  of  mercury  sufficiently  early. 

If  the  mother  be  infected  shortly  before  delivery, 
and  secondary  symptoms  do  not  appear  until  after 
the  birth  of  the  child,  it  stands  an  excellent  chance 
of  escaping  the  disease,  as  far  as  heredity  is  con- 
cerned, although  it  is  possible  that  it  is  in  ho  wise 
insusceptible  to  infection  by  inoculation,  either 
through  the  medium  of  the  lesions  present  in  the 
mother,  or  by  a  syphilitic  nurse,  if  such  be  ob- 
tained; and  the  latter  contingency  may  occur 
from  the  fact  that  syphilitic  nurses  are  intentionally 


172  Lectures  on  Syphilis. 

procured  in  some  instances  in  which  the  mother  is 
syphilitic  but  the  child  apparently  healthy,  the 
belief  being  that  syphilis  will  necessarily  develop 
in  the  latter,  and  that  it  cannot  by  any  possibility 
escape.  The  same  plan  is  also  advocated  when  the 
child  presents  unmistakable  evidences  of  the 
disease. 

It  is  undoubtedly  true,  that  certain  persons  are 
insusceptible  to  syphilis  and  that  the  susceptibility 
of  different  persons  varies  greatly,  as  in  the  case 
of  other  contagious  affections.  It  would  appear 
then,  more  rational  to  infer,  in  certain  of  the  cases 
of  children  born  syphilitic,  and  in  which  the 
mother  apparently  escapes,  that  she  was  primarily 
insusceptible  to  infection,  or  that  she  exhibited  a 
certain  power  of  resistance  to  it,  than  to  explain 
the  circumstance  by  "some  occult  and  indiscernible 
change  in  the  maternal  system. "  Might  not  the 
mother  have  a  sufficient  power  of  resistance,  to 
enable  her  to  escape  infection  through  the  foetus 
in  utero,  and  yet  remain  susceptible  to  inoculation? 
It  is  possible  too,  that  she  may  have  been  insuscep- 
tible to  syphilitic  infection  or  inoculation  during 
gestation,  and  yet  might  at  any  time  become  sus- 
ceptible, the  degree  of  susceptibility  varying  at 
different  times,  as  is  true  of  other  infectious  dis- 
eases. 


Lydston.  173 

In  case  the  mother  was  primarily  insusceptible 
to  both  infection  and  inoculation,  there  is  evidently 
no  danger  of  her  contamination  by  the  infant,  but 
it  is  of  course  impossible  to  determine  this.  Under 
any  of  the  other  circumstances  mentioned,  there  is 
evidently  an  element  of  danger. 

Another  consideration,  is  the  possible  analogy 
between  the  effects  of  the  infection  of  the  foetus, 
upon  the  mother,  and  vaccinia,  there  being  a  certain 
degree  of  immunity  from  syphilis  resulting,  which 
lasts  for  a  variable  length  of  time.  In  this  event, 
the  mother  may  become  susceptible  at  any  time 
during  lactation,  and  contract  the  disease  from  the 
infant.  It  is  possible  that  in  the  same  way,  the 
infant  may  enjoy  a  certain  amount  of  protection 
from  infection,  it  being  born  healthy  and  its  moth- 
er being  syphilitic,  although  it  may  at  any  time 
contract  the  disease  by  inoculation. 

If  the  mother  and  child  have  both  apparently 
escaped  syphilis,  although  it  is  present  in  an  active 
form  in  the  father,  it  is  evident  that  one  or  both  of 
them  may  be  syphilitic,  and  lesions  develop  at 
any  time,  with  a  consequent  danger  of  infection  in 
the  act  of  nursing,  for  it  is  impossible  to  say  in 
some  cases,  exactly  when  the  mother  becomes  in- 
fected. I  would  consequently  strenuously  object 
to  maternal  nursing  under  any  of  the  circumstan- 


174  Lectures  ON  Syphilis. 

ces  I  have  mentioned,  believing  that  there  is  a  cer- 
tain amount  of  danger  in  the  practice,  be  that  dan- 
ger ever  so  slight.  If  however,  the  mother  and 
child  are  both  undoubtedly  diseased,  and  the  phys- 
ical condition  of  the  mother  be  such  that  she  is 
able  to  nurse  her  infant,  and  her  milk  is  of  a  fair 
quality,  nursing  should  be  allowed.  It  is  evident 
that  if  the  mother  is  not  permitted  to  nurse  the 
child  for  the  reasons  I  have  stated,  an  artificial 
substitute  for  mother's  milk  must  be  given.  The 
same  rules  should  guide  us,  as  in  the  ordinary 
management  of  artificial  infant  feeding.  Although 
there  is  a  possibility  of  a  child  born  of  a  syphilitic 
mother,  escaping  the  manifestations  of  the  disease 
during  childhood,  only  to  become  the  subject  of  its 
lesions  later  in  life,  I  stiU  think  that  in  all  cases  it 
should  have  the  benefit  of  the  doubt,  and  should  be 
reared  by  artificial  feeding. 

The  mother,  if  syphilitic,  is  often  in  a  condition 
of  extreme  malnutrition,  thus  rendering  nursing 
not  only  injurious  to  the  child,  from  the  compara- 
tively inferior  quality  of  the  lacteal  secretion, 
especially  if  it  be  entirely  depended  upon  for  its 
support,  but  also  injurious  to  her,  by  causing  a  still 
further  drain  upon  her  fund  of  vitality  in  the  per- 
formance of  the  function  of  lactation.  But  it  may 
be    objected  that    "the   child,    if  syphilitic,  will 


Lydston.  175 

not  thrive  upon  artificial  nourishment,  inas- 
much as  it  is  already  the  subject  of  a  cachexia, 
with  its  concomitant  impairment  of  nutrition." 
Now  it  is  true,  that  in  case  the  mother  is 
in  good  condition  and  apparently  free  from  syph- 
ilis, her  milk  is  usually  far  the  best  fbod  for  the 
child,  and  gives  the  best  possible  prospects  of  rear- 
ing it;  but  this  fact  does  not  weigh  very  heavily 
in  the  balance  when  we  reflect  that  the  mother 
may  have  escaped  syphilitic  infection,  and  may.  pos- 
sibly be  infected  by  her  syphilitic  child  in  cage:  it 
be  allowed  to  nurse.  The  chance  of  the  ultimate 
survival  of  the  syphilitic  infant,  is  small  at  best, 
and  as  for  the  difierence  between  the  prospective 
usefulness  of  the  syphilitic  child,  and  the  possibly 
non-syphilitic  mother,  it  is  suflSciently  obvious. 
We  must  also  consider  the  fact  that  the  child,  even 
if  syphilitic,  may  attain  an  age  sufficient  to  enable 
it  to  withstand  the  tardy  lesions  of  the  disease,  and 
that  this  possibility  is  greatly  enhanced  by  the 
proper  performance  of  its  nutritive  functions,  which 
depends  almost  entirely  upon  good  and  sufficient 
nourishment,  which  it  cannot  obtain  from  a  cach- 
ectic mother.  In  case  a  woman  has  been  brought 
under  the  influence  of  mercury  before  delivery, 
and  the  child  be  born  and  remain  for  some  weeks 
free  from  syphilis,  there  is  a  possibility  of  its  escap- 


176  Lectukes  on  Syphilis. 

ing  the  disease  entirely,  unless  it  receives  it  from 
its  mother  by  inoculation,  and  inoculable  lesions 
may  occur  upon  her  at  any  time.  In  such  a  case 
the  possible  danger  of  contagion  should  warrant  us 
in  interdicting  nursing,  and  in  the  substitution  of 
artificial  food. 

The  practice  of  employing  a  syphilitic  nurse  to 
care  for  a  syphilitic,  or  possibly  non-syphilitic  in- 
fant, requires  but  little  comment,  as  there  are  few 
circumstances  which  would  warrant  it.  If  the 
child  present  unequivocable  evidences  of  syphilis; 
if  we  have  positive  evidence  that  the  nurse  has  had, 
or  has  the  disease,  and  she  is  in  good  condition,  her 
milk  being  of  good  quality,  she  may  be  employed. 
Under  all  other  circumstances,  I  should  most  em- 
phatically protest  against  nursing,  and  should  ad- 
vise an  artificial  substitute  for  the  mother's  milk. 


APPENDIX. 


APPENDIX. 


As  there  are  very  few  formulae  given  in  the  preceding-  lec- 
tures, it  has  been  thought  advisable  to  append  a  list  of  some 
of  the  more  useful  prescriptions  for  the  treatment  of  syphilis, 

IN   SECONDARY   SYPHILIS. 

R     Pil.  Hydrarg.  Protiod 1-5  gr.  q.  s. 

(Gamier  et  Lamoreux.) 
Sig. — Begin  with  one  pill  t.  d.  and  cautiously  increase   until 
physiological  effects  are  produced. 

R     Hydrarg.  Protiod - gr.  xx 

Ext.  Taraxici q.  s. 

M.  Ft.  pil.  No.  C. 

Sig. — From  three  to  eight  pills  daily  in  divided  doses. 

ft     Hydrarg.  Protiod gr.  xx 

Ext.   Hyoscyami gr.  x 

Sacch.   Lac 5'  i 

M.  Trit.  subtnis  et  ft.  chart,  No.  C. 

Sig. — One  to  six  powders  daily  at  re^lar  intervals.  Opium 
may  be  added  in  lieu  of  the  hyoscyamus,  should  gastro-intesti- 
nal  irritation  be  a  source  of  annoyance. 

ft     Hydrarg.    Biniod gr.  iv 

Ext.  Hyoscyami gr.  x 

M.  Ft.  pU.  No.  Ix. 

Sig. — One  pill  three  or  four  times  daily.  To  be  used  only 
when  the  stomach  is  extremely  tolerant. 


180  Appendix. 

R    Pil.  Hydrarg gr-  c 

Ferri.  Sulph.  Exsiccat gr.  1 

M.  Ft.  pil.  No.  1. 

Sig. — One  to  eight  pills  daily.  Bumstead's  pil.  duo.  espec- 
ially useful  in  anaemic  patients,  and  as  a  tonic  in  late  syphilis. 

R     Hydrarg.    Tannat gr.  x 

Ext.  Lactuc gr.  xxx 

M.  Ft.  pil.  No.  xxx. 

Sig. — One  to  five  pills  daily.  Especially  recommended  as 
unlikely  to  produce  gastro-intestinal  disturbance. 

R     Hydrarg  Bichlor gr.  iv 

Kalii  lod ^ ^  vi 

Elix.  Simp ^  iv 

M.  Sig.  — ^i  in  water  after  each  meal.  The  "mixed  treatment" 
for  late  secondary  lesions  and  the  period  of  sequelae,  and  to 
alternate  with  mercury  during  the  entire  course  of  syphilis, 

R     Hydrarg.  Bichlor gr.  iv 

Sodii    Chloridi jii 

Aquae  Dest ^  xiii 

M.  Sig. — For  hypodermic  use.     Dose  mxxx.* 

R     Hydrarg.  Bichlor gr.  ix 

Sodii  Chloridi gr.  xl 

Aquae  Dest ^  iv 

M. — Add  the  albumen  of  one  egg  and  filter.  Dose  M.  xv 
hypodermically .  f 

N.  B. — It  should  be  remembered  that  the  bichloride  cor- 
rodes the  needles  and  makes  them  brittle,  hence  care  is  neces- 
sary not  to  break  them  ofiE  in  the  tissues.  They  should  be 
kept  well  oiled,  to  prevent  corrosion. 

*  Stem.    Progres  Medicale,  Paris,  1878. 

+  Staub.  "  Treatment  of  syphilis  by  hypodermic  injections  of  the 
chloro-albuminate  of  mercmry,", Paris,  1872.  This  mixture  decom- 
poses readily  and  tends  to  become  cloudy.  It  must  be  freshly  pre- 
pared, and  carefuUy  filtered. 


Appendix.  181 

for  late  secondary,  malignant  or  precocious  syphi- 
lis, and  the  period  op  sequels. 

ft    Kalii  lod 5  vji 

Hydrarg.  Bichlor gr.  ii 

Tr.    Quassias ^  iv 

M.  Sig.  — Dose  ^i  well  diluted. 

ft     Aramonii  Carbonat 3  i  ss 

Kalii  lod 3  iii 

Syr.  Sarsse  Comp. 

Aquae  Dest aa. .  ^  ii  ss 

M.  Sig. — 31  ttree  or  four  times  daily. 

Prof.  Gunn's  "three- eights"  mixture. 

ft     lodinii  Resub gr.  viii 

Kalii  lod 5  viii 

Syr.  Sarsse  Co ^  viii 

M.  Sig. — ^i  three  or  four  times  daily. 

FOR  INFANTILE   SYPHILIS, 

ft     Sodii  Bicarb gr.  xx 

Hydrargyri  cum.  cretae gr.  xl 

M.  Ft.  chart,  No.  xx. 

Sig. — One  four  times  daily. 

ft     Hydrargyri  Chlor.   Mit gr.  ii 

Sacchari  Lac gr.  xx 

M.  Trit.  subtilis  et  ft.  chart,   No.  xx. 
Sig, — One  four  times  daily.  ' 

N.  B. — In  children  who  are  old  enough  to  take  them,  the 
parvules  of  mercury  vp^ith  chalk,  and  of  calomel,  which  are  sold 
in  the  shops,  are  an  excellent  form  for  administration. 


182  Appendix. 

tonics  for  the  syphilitic  cachexia  and  late  syphilis. 

R     Hydrarg-.   BicMor gr.   ss 

n.  Ext.  Berberis  Aq. 

Tr.  Cinchon.  Co aa.  .  ^  ii 

M.  Sig. — 3ii  after  each  meal. 

R     Hydrarg.  Biclilor gr.  ss 

n.  Ext.  Rumicis  Crisp. 

Fl.  Ext.  Cascarse  Sag aa . .  ^  ii 

M.  Sig. — gii  after  each  meal. 

R     Liq.  Arsen.  et  Hydrarg.  lod 5  i^s 

Tr.    Cinchon.  Co ^  iv 

M.  Sig.— 3i  after  each  meal. 

R     lodof ormi gr.  xx 

Ferri  Sulph.  Exsic gr.  xl 

M.  Ft.  pil.  No.  XX. 

Sig. — One  four  times  daily. 

LOCAL   TREATMENT   OP   SYPHILIS. 

FOR  THE   CHANCRE. 

LOTIO  FLAVA. 

R    Hydrarg.    Bichlor gr.  xviii 

Aquae   Calcis ^  x 

M.  Sig. — Lotion. 

LOTIO  NIGEA. 

R     Hydrarg.  Chlor.   Mit gr.  xxx 

Aquae  Calcis ^  x 

M.  Sig. — Lotion. 

R    Ferri  et  Pot.  Tart gr.  xx 

AquEe ^  iv 

M.  Sig. — Lotion.     In  phagedaenic  chancre. 


Appendix.  183 

R     Hydrarg.  Oleat 10%.  ^  i 

Vaselinse ^  i 

M.  Sig. — Ungt.    For  application  to  non-ulcerated  indurations. 

R     Hydrarg.  Chlor.   Mit 3  ii 

Zinci  -  Oxide 5  ii 

M.  Trit.  Subtil.  Sig. — Apply  twice  daily,  after  drying  the 
surface  with  bibulous  paper. 

FOR    THE    SYPHILIDES. 

R    Hydrarg.  Oleat 20%. .  ^  i 

Cerati  Simp ^  i 

M.  Sig.— Ungt. 

R     Hydrarg.  Bichlor gr.  iv 

Tr.  Benzoini  Co ^  ii 

M.  Sig. — Apply  with  brush  once  daily.  Especially  useful  in 
sluggish  ulcerations. 

R     Hydrarg.     Bichlor gr.  iv 

Tr.  Myrrh ^  i 

M.  Sig. — Apply  with  brush  once  daily. 

R     Hydrarg.  Bichlor gr.  xx 

Collodionis ^  i 

M.  S'ig. — Apply  every  second  day  until  skin  shows  signs  of 
irritation,  or  lesions  yield.  Especially  useful  in  condylomata 
and  scaly  lesions. 

FOR  MUCOUS  PATCHES  AND  BUCCAL  ULCERATIONS. 

R     Acid  Chromici gr.  x 

Aquas  Dest ^  i 

M.  Sig. — Apply  with  brush  several  times  daily. 

R     Liq.  Hydrarg.    Mtrat q.  s 

Sig. — To  be  applied  with  glass  rod,  after  careful  drying  of 
the  surface. 


184  Appendix. 

in  laryngeal  syphilis. 

R     Iodoform] 3  ii 

Glycerinae ^  i 

M.  Sig. — Apply  daily  witli  sponge  probang. 

R.     lodof  ormi 3  i 

^ther  Sulph... ^  i 

M.  Sig.-  -Apply  daily  witli  sponge  probang. 

FOR  BONE   AND   JOINT   LESIONS   IN    LATE    SYPHILIS,    AND   TU- 
BERCULAR  SYPHILIDES. 


R    Hydrarg.  Oleatis 10% 

Ung.  lodinii  Comp aa . .  ^  i 

M.  Sig, — Apply  at  bed-time. 


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